Whitcomb  & Barrows 


Digitized  by  the  Internet  Archive 
in  2016 


https://archive.org/details/obstetricsfornur00dele_0 


From  an  old  Italian  wax  carving,  evidently  modeled  after 
Hunter’s  plates. 


one  of 


OBSTETRICS 

FOR 

NURSES 


BY 

JOSEPH  B*J^lLEE,  A.M.,  M.D. 

Professor  of  Obstetrics,  Northwestern  University  Medical  School ; Obstet^ 
rician  to  Mercy,  Wesley,  Provident,  Cook  County,  and  Chicago  Lying-in 
Hospitals;  Lecturer  in  the  Nurses’  Training  Schools  of  Same 


FOURTH  EDITION,  THOROUGHLY  REVISED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 


*914 


•Dm 

IM 


MSilui  Ut.  - iLiEfifiBt 

OffiSrMW  HIU,  MA  Q2IW 


Copyright,  1904,  by  W.  B.  Saunders  and  Company.  Reprinted  October,  1904 
Revised,  reprinted,  and  recopyrighted  July,  1906.  Reprinted  February,  1907, 
and  November,  1907.  Revised,  reprinted,  and  recopyrighted  June,  1908. 
Reprinted  January,  1909,  June,  1909,  January,  July  and  October,  1910, 

March,  August  and  November,  1911.  Reprinted  March,  1912,. 

October,  1912,  and  February,  1913.  Revised,  entirely 
reset,  reprinted,  and  recopyrighted  July,  1913. 


Copyright,  1913,  by  W.  B.  Saunders  Company. 


Reprinted  August,  1914,  and  November,  1914 


PRINTED  IN  AMERICA 


PRESS  OF 

W.  B.  SAUNDERS  COMPANY 
PHILADELPHIA 


TO 

“THE  WOMAN  ABOUT  TO  BECOME  A MOTHER 
OR  WITH  THE  NEW-BORN  INFANT  UPON  HER  BOSOM, 
WHEREVER  SHE  BEARS  HER  TENDER  BURDEN,” 


THIS  BOOK  IS  RESPECTFULLY  DEDICATED, 


PREFACE  TO  THE  FOURTH  EDITION 


For  this,  the  fourth  edition,  both  text  and  illus- 
trations were  thoroughly  worked  over.  In  the  text 
few  changes  were  necessary,  the  fundamentals  of  ob- 
stetric nursing  remaining  about  the  same  from  year 
to  year.  Several  subjects  were  added,  such  as  the 
after-care  of  fistula  operations,  Momburg’s  treatment 
for  hemorrhage,  and  blood  transfusion.  The  chapter 
on  Infant  Feeding  was  revised  by  Dr.  F.  X.  Walls; 
that  on  Cesarean  Section  was  much  amplified  in  view 
of  the  more  generalized  performance  of  the  operation, 
and  the  latest  scientific  discoveries  of  interest  to  the 
nurse  were  mentioned. 

A number  of  new  illustrations  have  been  added, 
and  some  of  the  old  replaced  by  improved  drawings 
and  photographs.  Four  new  colored  plates  also  have 
been  inserted. 

Joseph  B.  De  Lee. 

5028  Ellis  Avenue,  Chicago,  III. 


7 


PREFACE 


Although  this  book  is  intended  primarily  for  nurses, 
the  author  believes  that  medical  students  will  find  some- 
thing of  value  in  it,  since  the  duties  of  a nurse  often  de- 
volve upon  them  in  their  early  years  of  obstetric  practice. 

There  are  really  two  subjects  considered  in  the  book, — 
obstetrics  for  nurses  and  the  actual  obstetric  nursing, — 
and  the  author  has  sought  to  combine  them  so  that  the 
relations  of  one  to  the  other  might  be  natural  and 
mutually  helpful  in  presenting  this  branch  of  medicine  in 
a clear  and  interesting  form. 

The  illustrations  are  nearly  all  original,  and  were  made 
expressly  for  the  work.  The  photographs  were  taken 
by  the  author  from  actual  scenes,  and  the  reader  is  in- 
vited to  study  the  details,  as  especial  care  was  taken  to 
render  the  pictures  true  to  life  in  every  respect. 

The  text  is  the  outgrowth  of  eight  years’  lecturing  to 
the  nurses  of  four  different  training  schools. 

For  the  preparation  of  the  dietary  the  author  acknowl- 
edges his  thanks  to  Mrs.  E.  E.  Koch,  Superintending 
Nurse  of  the  Chicago  Lying-in  Hospital,  and  for  the 
chapter  on  the  Infant’s  Layette  he  is  indebted  to  Miss 
Katherine  DeWitt,  who  does  private  nursing  for  many 
of  his  cases. 


9 


TO 


PREFACE 


Dr.  F.  X.  Walls  kindly  allowed  the  publication  of  a 
method  of  milk  modification  devised  by  him. 

Further,  the  author  thanks  those  nurses  and  internes 
who  have  aided  and  posed  in  the  settings  for  the  photo- 
graphs, and  the  publishers,  who  have  spared  no  effort  in 
the  production  of  the  illustrations. 


JOSEPH  B.  DeLEE, 


CONTENTS 


Introduction 


PAGE 

7-7 


PART  I 

Anatomy  and  Physiology  of  the  Reproductive  System 
CHAPTER  I 

Anatomy  of  the  Female  Generative  Organs 21 

The  Bony  Pelvis,  21 — Varieties  of  Pelves,  26 — The  Soft  Parts, 

28 — The  Uterus,  28 — The  Bladder,  31 — The  Rectum,  31 — 

The  Peritoneum,  31 — The  External  Genitals,  31 — The  Vulva, 

32 — The  Perineum,  33 — The  Anus,  34 — The  Breasts,  35. 

CHAPTER  II 

Physiology 37 

The  Function  of  Reproduction,  37 — Ovulation,  37 — Puberty, 

37 — Menstruation,  38 — Conception,  40 — The  Physiology  of 
the  Fetus  in  the  Uterus,  46— The  Placenta,  46. 

CHAPTER  III 

Pregnancy,  Labor,  and  the  Puerperium 49 

Maternal  Changes  in  Pregnancy,  49 — Labor,  54 — Lighten- 
ing, 55 — False  Pains,  56 — The  Show,  57 — The  Labor  Pains, 

58 — The  Bag  of  Waters,  59 — The  Puerperium,  61 — The 
Uterus,  61 — The  Lochia,  63 — The  Breasts,  65 — General 
Changes  in  the  Puerperium,  66 — The  Kidneys,  66 — The 
Bowels,  67 — The  Skin,  67 — The  Mental  Condition,  67. 

CHAPTER  IV 

The  Newborn  Infant 68 

The  Baby  in  the  First  Weeks,  68 — The  Cry  of  a Newborn 
Infant,  68 — Sleep,  69 — Temperature,  69 — The  Skin,  69 — 

The  Navel,  70 — The  Baby’s  Bowels,  70 — The  Kidneys,  70 — 

The  Weight,  71. 


11 


12 


CONTENTS 


CHAPTER  V 

The  Hygiene  of  Pregnancy 

Diagnosis  of  Pregnancy,  73 — Diagnosis  of  Time  of  Confine- 
ment, 74 — Mode  of  Living  for  the  Pregnant  Woman,  75 — 
Dress,  75 — Preservation  of  the  Figure,  78 — The  Diet,  80 — 
Exercise,  81 — The  Mind  during  Pregnancy,  and  Maternal 
Impressions,  82 — The  Determination  of  Sex,  83 — The 
Bowels,  84 — The  Kidneys,  86 — Toxemia,  87 — Bathing,  87 — 
Care  of  the  Genitals,  89 — Care  of  the  Breasts,  89 — The  En- 
gagement of  the  Nurse,  90 — Rules  for  the  Obstetric  Nurse, 
92 — Sterilizing,  92 — The  Nurse’s  Visit,  95. 

CHAPTER  VI 

The  Infant’s  Layette 

The  Wardrobe,  97 — Nursery  Conveniences,  100. 


PART  II 

Nursing  During  Labor  and  in  the  Puerperium 

CHAPTER  I 

Care  during  Labor 

Care  during  the  First  Stage,  103 — Preparation  of  the  Room, 
105 — Preparation  of  the  Bed,  107 — Preparation  of  the 
Patient,  109 — Preparation  for  the  Doctor,  no — The  Diet  in 
the  First  Stage,  113 — The  History-sheet,  114 — General  In- 
structions, 1 14 — -The  Husband,  117 — When  to  Summon  the 
Doctor,  117 — Care  during  Second  Stage,  118 — Scopolamin 
and  other  Anesthetics,  120 — Care  during  Third  Stage,  125 — 
Perineorrhaphy,  129 — The  First  Care  of  the  Newborn 
Child,  132 — Care  after  the  Third  Stage,  134. 

CHAPTER  II 

Care  during  the  Puerperium 

Daily  Care  of  the  Mother,  135 — The  Breasts,  135 — Care  of 
the  Genitals,  138 — Special  Care  in  Cases  of  Complete 
Laceration  of  Perineum,  140 — The  History-sheet,  141 — 
Diet,  141 — The  Bowels,  144 — The  Bladder,  145 — Catheteri- 
zation, 146 — Sleep,  147 — General  Treatment,  147 — Visitors, 
148 — The  Time  of  Getting  Up,  148 — Nursing  after  Patient 
is  Up,  150. 

CHAPTER  III 

Care  of  the  Child 

Visitors,  15 1 — Bathing,  151 — Care  of  the  Navel,  154 — The 
Eyes,  155 — The  Bowels,  156 — The  Diaper,  159 — Urination, 
159 — Nursing,  160 — The  Diet,  164 — Weighing  the  Infant, 
166 — The  Temperature,  Pulse,  and  Respiration,  167 — 
Training  the  Baby,  167. 


PAGE 

73 


97 


103 


135 


CONTENTS 


13 


CHAPTER  IV 

PAGE 

Presentations  and  Positions 169 

The  Diagnosis  of  Presentation  and  Position,  173 — Breech 
Cases,  Shoulder,  or  Transverse  Presentation,  177. 

CHAPTER  V 

Obstetric  Operations 178 

Preparation  for  Operation,  180 — Preparation  of  the  Room, 

183 — Preparation  of  the  Patient,  184 — Preparation  of  In- 
struments, 187 — Light  and  Heat,  187 — Anesthesia,  188 — 
Care  after  Operations,  188 — Care  of  the  Child,  189— Care 
of  the  Mother,  190 — Major  Operations,  190 — The  Forceps, 

190 — Duties  of  Nurse  during  Forceps  Operation,  193 — 

The  Walcher  Position,  195 — The  Breech  Extraction,  196 — 
Version,  197 — Decapitation,  197 — Craniotomy,  198 — Prepa- 
ration for  Mutilating  Operations,  200 — Baptism,  200 — 
Cesarean  Section,  201 — Preparation  for  Cesarean  Section,  203 
— Light,  Heat,  and  Anesthetic,  207 — The  Operation,  208 — 

The  After-care,  209 — Convalescence,  210 — Vaginal  Cesarean 
Section,  210 — Symphysiotomy,  21 1 — Pubiotomy  or  Hebos- 
teotomy,  21 1 — The  Operation,  212 — After-care  of  Sym- 
physiotomy and  Pubiotomy,  214 — Minor  Operations,  217 — 
Preparation  of  Patient  for  Examination,  217- — Perineor- 
rhaphy, 218 — Removal  of  Sutures,  220 — Uterine  Tampon- 
ade, 220 — The  Douche,  222 — The  Vaginal  Douche,  223 — 

The  Uterine  Douche,  224 — -Uterine  Curettage,  224 — The 
Administration  of  Saline  Solution,  225 — The  Induction  of 
Premature  Labor,  230 — Therapeutic  Abortion,  234. 


PART  III 

The  Pathology  of  Pregnancy,  Labor,  and  the  Puerperiom 

CHAPTER  I 

Obstetric  Complications 237 

Disorders  of  Pregnancy,  237 — Nausea  and  Vomiting,  237 — 
Hyperemesis  Gravidarum,  238 — Prevention  of  Decubitus, 

242 —  Toxemia  of  Pregnancy,  242 — Edema  of  the  Extremities, 

243 —  Varicose  Veins,  243 — Leukorrhea,  245 — Pruritus,  245 
— Pendulous  Abdomen,  246 — Pain  in  the  Abdomen,  247 — 
Heartburn,  248 — The  Teeth,  248 — Frequent  Urination, 

248 — Fainting,  248 — Melancholia,  249 — Hemorrhages  dur- 
ing Pregnancy,  249 — Abortion,  249 — Placenta  Pnevia,  250 — 
Premature  Detachment  of  the  Placenta,  251 — Extra-uterine 
Pregnancy,  252 — Duties  of  the  Nurse,  255 — Eclampsia,  256. 

CHAPTER  II 

Complications  during  Labor 262 

Breech  Presentation,  269 — Prolapse  of  the  Cord,  270 — Hem- 
orrhages during  Labor,  272 — Postpartum  Hemorrhage,  272. 


14 


CONTENTS 


CHAPTER  III 

Complications  of  the  Puerperium 

Puerperal  Infection,  279 — Frequency  and  Source,  283 — 
The  Prevention  of  Puerperal  Infection,  284 — The  Asepsis  of 
the  Nurse,  285 — Symptoms,  286 — Treatment  of  Puerperal 
Infection,  287 — Nourishment,  289 — Rectal  Infusion  of 
Saline  Solution,  289 — Medicinal  Treatment,  293 — Surgical 
Treatment,  293 — The  Child,  293 — The  Nurse,  294 — The 
Plistory-sheet,  295 — Disinfection,  296 — Puerperal  Throm- 
bosis, 297 — Phlegmasia  alba  dolens,  297 — After-pains,  299 — 
Tympany,  299 — Constipation,  300 — Vesico- vaginal  Fistula, 
301 — Cystitis,  303 — Headache,  304 — Puerperal  Insanity,  304. 

CHAPTER  IV 

Complications  of  the  Puerperium  ( Continued ) 

Diseases  of  the  Breasts,  307 — Simple  Engorgements,  307 — - 
Abnormalities  of  the  Nipples,  312 — Cracks,  Fissures,  and 
Blisters  of  the  Nipple,  313 — Mastitis,  315 — Galactorrhea  or 
Excess  of  Milk,  321 — Agalactia  or  Scarcity  of  Milk,  321 — 
Abnormal  Milk,  325 — Drying  up  the  Milk,  326 — Care  of  a 
Wet-nurse,  326. 

CHAPTER  V 

The  Disorders  of  the  First  Weeks  of  Life 

Affections  of  the  Digestive  Organs,  328 — Indigestion,  328 — 
Colic,  329 — Difficult  Nursing,  330 — Vomiting,  330 — Con- 
stipation, 330 — Diarrhea,  331 — Green  Stools,  332 — Inani- 
tion Fever,  333 — Thrush  or  Sprue,  333 — Bednar’s  Aphthae, 

334 —  Marasmus,  334 — Affections  of  the  Respiratory  Tract, 

335 —  -Snuffles,  335 — Coryza,  336 — Bronchitis  and  Pneumo- 
nia, 336 — Cyanosis  or  Blue  Babies,  337 — Affections  of  the 
Urinary  Organs,  337 — Delayed  Urination,  337 — Uric  Acid, 
338 — Phimosis,  338 — Circumcision,  338 — Dilatation,  341 — 
Affections  of  the  Skin,  341 — Jaundice,  341 — Eruptions  of  the 
Skin,  342 — Vesicular  Eruptions,  342 — Chafing,  or  Eciema 
Intertrigo,  343 — Other  Affections  of  the  Newborn  Infant, 
344 — -Enlargement  of  the  Breasts,  344 — Vulvitis,  345 — 
Menstruation,  345— Delayed  Separation  of  the  Cord,  345 — 
Granulations  of  the  Navel,  345 — Infections  of  the  Newborn, 
346 — Infection  of  the  Umbilicus,  346 — Infection  of  the  Eyes, 
or  Ophthalmia  Neonatorum,  347 — Care  of  the  Nurse  Herself, 
352 — Infection  of  the  Mouth  and  Throat,  352 — Hemorrhages 
in  the  Newborn,  352 — Operative  Injuries,  353 — Injuries  to 
the  Brain,  355 — Caput  Succedaneum,  356 — Cephalhe- 
matoma, 356 — Congenital  Deformities,  356 — Monstrosities, 
356 — Harelip,  356 — Cleft  Palate,  356 — Occlusion  of  the  Anus 
or  Imperforate  Anus,  356 — Tongue-tie,  357 — Supernumerary 
Fingers  and  Toes,  358 — Hernia,  358 — Sundry  Complications, 
358 — Convulsions,  358 — Lockjaw  or  Tetanus,  359 — Com- 
plications due  to  the  Use  of  Hot-water  Bags,  359 — Overlying 
the  Child,  360 — Asphyxia  Neonatorum,  360. 


CONTENTS 


15 


CHAPTER  VI 

PAGE 

The  Care  of  Premature  Infants 365 

The  Incubator  or  Couveuse,  368 — Care  of  the  Incubator, 

373 — The  Ventilation,  375 — The  Bed,  375 — The  Dress,  376 
—Warm  Feet,  377— The  Diet,  378 — Method  of  Feeding,  380 
— The  Bath,  384 — The  Care  of  the  Eyes,  Nose,  Mouth,  etc., 

385 — General  Care,  386 — Removal  from  the  Incubator,  386 
— The  Particular  Diseases  of  Premature  Infants,  387 — 
Thrush  or  Sprue,  388 — Nasal  Infection,  388 — Cyanosis,  389 
— Atelectasis  Pulmonum,  390 — Convulsions,  390. 

CHAPTER  VII 

Infant  Feeding 392 

Contraindications  to  Maternal  Nursing,  393 — Obtaining 
Milk  for  Analysis,  394 — Substitutes  for  Mothers’  Milk,  395 — 
Amount  of  Food  at  a Feeding,  400 — The  Caloric  Method  of 
Feeding,  402 — Filling  the  Bottles,  403 — Sterilization  of  Milk, 

403 — Quality  of  the  Milk,  404 — Whey,  406 — Peptonized 
Milk,  407— Barley-water,  407 — Beef-juice,  408 — Artificial 
Infant  Foods,  408. 


APPENDIX 

Visiting  Nursing  in  Obstetric  Practice 411 

Care  during  Fabor  Among  the  Destitute,  41 1 — Duties  dur- 
ing the  Puerperium,  414. 

Hospital  vs.  Home  Nursing 419 


Ward  Care,  419 — In  the  Nursery,  420 — Recording  of  Symp- 
toms, 421 — Prevention  of  Accidents,  421 — Orders,  422 — 
Relations  to  the  Patient,  423 — Economy,  423 — Methods  of 
Sterilization,  424 — Sterilization  of  the  Hands,  424 — Ftir- 
bringer’s  Method,  425 — Hot-water  and  Alcohol  Method  of 
Ahlfeld,  425 — Halsted’s  Permanganate  Method,  425 — 
Author’s  Method,  426 — Rubber  Gloves,  426 — Sterilizers, 
430 — Sterilization  by  Dry  Heat,  431 — Preparation  of  In- 
struments, 432 — Sterilization  of  Brushes,  433 — Preparation 
of  Dressings,  433 — Newspapers,  435 — Lysol  Gauze  for  Tam- 
ponade, 435 — Plain  Sterilized  Gauze,  437 — Iodoform  Gauze, 

437 —  Gelatin  Gauze,  437 — Suture  Material,  438 — Catgut, 

438 —  Silk,  438 — Linen  Suture  Yarn,  439 — Linen  Bobbin  for 
Tying  the  Cord,  439 — Basins,  Pitchers,  Douche-cans,  Bed- 
pans,  etc.,  439 — Gowns,  Aprons,  Leggins,  Towels,  Sheets,  and 
Pillow-slips,  440 — Tables,  Chairs,  the  Bed,  and  other  Fur- 
niture, 440 — Sterilizing  Apartments,  440 — Preparation  of 
Solutions,  441 — Sterile  Water,  441 — Bichlorid  of  Mercury 
Solutions,  442 — Carbolic  Acid  Solution,  443 — Lysol  Solution, 
443 — Formalin  Solution,  443 — Chinosol,  443 — Creolin,  443 — 
Salt  Solution,  443 — Boric  Acid  Solution,  444. 


16 


CONTENTS 


The  Obstetric  Nurse 

The  Nurse’s  Dress,  446 — Deportment,  446 — Venereal  Dis- 
eases, 448 — Gonorrhea,  448 — Syphilis  or  “Specific  Disease,” 
449 — General  Consideration  of  Venereal  Disease,  451. 

Dietary 

List  of  Diets,  452: — Absolute  Milk  Diet,  452 — Liquid  Diet, 

452 —  Semisolid  Diet,  452 — Diet  for  the  Prevention  of  Over- 
growth of  the  Child,  452 — Prochownik’s  Diet,  452 — Recipes, 

453 —  Albumin  or  Egg-water,  453— Barley-water,  453 — 
Beef-tea,  453 — Beef-juice,  453 — Beef-tea  with  Acid,  453 — 
Cereal  Extract,  454 — Chicken  Broth,  454 — Clam  Broth,  454 
—Champagne  Whey,  454— Egg  Lemonade,  454— Eggnog, 

454 —  Flaxseed  Tea,  455 — Flour-ball,  455 — Gum-arabic 
Water,  455 — Junket,  455 — Koumiss,  455 — Meat  Cure,  455 — 
Meat  Diet,  Raw,  456 — Meat-extract  Ice,  456 — Milk  and 
Egg,  456 — Milk  Digested  with  Acid,  456 — Milk,  Peptonized, 
Cold  Process,  456 — Warm  Process,  457 — Milk-toast,  Pep- 
tonized, 457 — Milk,  Sterilized,  457 — Milk-shake,  457 — 
Mutton  Broth,  457 — Nutritious  Coffee,  457 — Rice-water, 
458 — Rum  Punch,  458 — Toast-water,  458 — Whey,  458 — 
Wine  Whey,  458 — Rectal  Feeding,  459 — General  Rules,  459 
— Salt  Solution,  459 — Peptonized  Milk,  45c,  —Peptonized 
Milk  with  Egg,  459 — Digested  Beef,  460 — Fee  ng  Through 
the  Skin.  460 — Nasal  Feeding,  461. 

Glossary 


PACK 

444 


452 


Index 


463 

489 


Obstetrics  for  Nurses 


INTRODUCTION 

Statistics  show  that  of  every  250  women  who 
become  pregnant,  at  least  1 dies.  Seven  per  cent,  of 
the  deaths  of  women  between  the  ages  of  twenty  and 
forty  years  are  due  to  puerperal  infection.  Con- 
servatively estimated,  20,000  women  die  every  year  in 
the  United  States  from  the  immediate  and  remote  effects 
of  childbirth. 

Thousands  of  women  enter  our  hospitals  each  year  for 
the  repair  of  injuries  acquired  during  delivery,  and  seek- 
ing relief  from  the  diseases  caused  by  child-bearing. 

Nearly  one- third  of  the  blind  people  in  this  world 
have  lost  the  light  of  day  because  of  the  ignorance  or 
the  carelessness  of  the  attendants  at  the  time  of  birth. 

What  are  the  causes  of  these  evils?  The  standard  of 
obstetric  practice  is  low.  The  people  are  allowed  to 
believe  that  labor  is  a natural  process  and  requires  no 
special  care.  Therefore  men  with  the  best  minds,  with 
the  greatest  skill,  find  their  endeavors  better  rewarded  in 
other  fields  of  medical  practice. 

The  public  will  not  recognize,  either  with  appreciation 
or  with  remuneration,  the  strenuous  labors  of  the  ac- 
coucheur, the  nights’  rest  lost,  the  interference  with  his 
other  practice,  the  nervous  wear  and  tear,  and  the 
actual  technical  skill  he  exhibits.  Small  wonder  then 


2 


17 


INTRODUCTION 


18 

that  the  field  is  deserted  save  by  those  who  do  the  work 
to  maintain  a family  clientele. 

The  nurse  may  do  much  to  aid  the  physician  in  obtain- 
ing from  the  public  that  recognition  for  obstetrics  that 
the  specialty  so  justly  deserves. 

First,  she  may  urge  on  the  woman  the  importance  of 
consulting  the  accoucheur  early  in  pregnancy,  so  that 
complications  may  be  anticipated  and  avoided.  Second, 
she  may  aid  the  physician  in  obtaining  aseptic  conditions 
during  the  labor.  The  nurse  should  prepare  for  a con- 
finement just  as  she  would  prepare  for  a vaginal  hyster- 
ectomy. She  will  meet  opposition  in  this  endeavor, 
especially  from  the  older  members  of  the  family,  but 
quiet  insistence  will  be  successful.  She  may  explain  to 
the  patient  that  all  the  preparations  are  not  because 
trouble  is  expected,  but  for  the  purpose  of  preventing 
trouble,  and  that  accidents  are  more  likely  to  occur  if 
such  preparations  are  not  made. 

The  nurse  may  allay  the  alarm  of  the  parturient  and 
the  family  when  the  accoucheur  asks  for  sufficient  medi- 
cal assistance.  Most  deliveries  are  accomplished  by  the 
physician  alone,  with  the  nurse  and  such  help  as  the 
husband  and  a courageous  neighbor  may  give.  The 
accoucheur  often  has  to  work  over  a low  bed,  and  in  a 
small  room  with  insufficient  light.  The  people,  from 
long  custom,  regard  this  proceeding  as  good.  It  is  bad. 
This  makeshift  method  is  unjust — unjust  to  the  par- 
turient, to  the  unborn  child,  and  to  the  doctor  and  the 
nurse.  No  surgeon  tolerates  such  conditions. 

Compare  the  advantages  of  the  surgeon  in  his  capa- 
cious operating  room,  with  good  light,  sterile  utensils, 
many  nurses  and  assistants,  with  the  plight  of  the 
obstetrician.  Thus  it  is  not  far  to  go  to  explain  the  exist- 
ence of  the  evils  referred  to  in  the  opening  paragraphs. 

Why  should  not  the  woman  about  to  perform  the 


INTR  OD  UCTION 


19 


highest  function  of  the  race,  at  the  most  interesting, 
most  endearing,  and  the  crucial  moment  of  her  life, 
enjoy  the  greatest  benefits,  the  finest  art  that  the  science 
of  medicine  affords? 

Thus  in  many  ways  the  nurse  may  smooth  the  path 
for  the  advance  of  the  obstetric  art.  She  becomes  really 
a missionary,  spreading  the  gospel  of  good  obstetrics. 

By  the  power  of  good  example  and  by  precept  she 
will  instil  in  the  public  mind  a knowledge  of  the  impor- 
tance of  obstetrics  and  will  engender  a respect  for  the  art 
which  will  soon  result  in  a demand  for  higher  standards 
of  practice,  and  this  demand  will  draw  to  the  specialty 
the  best  medical  and  nursing  talent  the  community 
possesses. 

Thus  her  efforts  will  redound  to  the  benefit  of  the 
medical  profession,  of  which  she  is  a part,  and  lastly  and 
mostly  to  the  community — the  people.  Only  in  this 
way  may  we  hope  to  see  the  frightful  mortality  tables 
shrink,  and  our  hospitals  emptied  of  women  seeking 
relief  from  the  injuries  and  diseases  caused  by  pregnancy 
and  labor. 

In  this  book  the  subject  is  divided  into  three  parts. 
In  the  first  part  the  anatomy  and  physiology  of  the 
whole  reproductive  cycle  is  considered — that  is,  a de- 
scription is  given  of  the  various  processes,  the  changes 
in  the  genitals  and  general  system,  occurring  during 
pregnancy,  labor,  and  the  puerperium. 

The  second  part  deals  with  the  conduct  or  manage- 
ment of  pregnancy,  labor,  and  the  puerperium.  The 
nurse  is  told  how  to  care  for  a woman  during  each  of 
these  periods  of  the  normal  reproductive  cycle. 

The  third  part  treats  of  the  pathology  of  pregnancy, 
labor,  and  the  puerperium.  In  this  part  are  considered, 
from  the  nurse’s  standpoint,  the  complications  which 
may  disturb  the  normal  course  of  the  three  stages  of 


20 


INTR  0D  UCTION 


reproduction,  and  how  the  nurse  may  do  her  share  of  the 
work  of  saving  both  patients  from  their  baneful  effects. 

In  addition,  there  follow  a few  chapters  on  allied  sub- 
jects, such  as  dietary,  visiting  nursing,  and  hospital  and 
home  nursing. 

by  keeping  these  divisions  of  the  subject  in  mind  the 
nurse  will  find  the  study  much  simplified,  and  the  book 
will  be  more  easily  grasped  and  rendered  applicable  to 
every-day  practice. 

It  is  not  to  be  understood  that  the  treatment  recom- 
mended in  this  book  is  to  take  the  place  of  the  doctor’s 
orders.  The  nurse  should  learn  the  practice  of  the 
physician  with  whom  she  works,  and  carry  out  this  prac- 
tice in  his  cases.  The  author  hopes  that  the  book  will 
be  of  help  to  her  when  she  is  on  her  own  responsibility 
and  for  her  general  information. 


PART  I 


ANATOMY  AND  PHYSIOLOGY  OF  THE 
REPRODUCTIVE  SYSTEM 


CHAPTER  I 

ANATOMY  OF  THE  FEMALE  GENERATIVE 
ORGANS 

The  parts  of  the  woman’s  person  with  which  the  ob- 
stetric nurse  has  particularly  to  do  are  the  pelvis,  includ- 
ing the  soft  parts,  and  the  breasts. 


The  Bony  Pelvis. — The  bony  pelvis  (Figs.  1-3)  is 
that  part  of  the  skeleton  interposed  between  the  trunk 

21 


Fig.  1. — Normal  female  pelvis. 


22  ANATOMY  OF  FEMALE  GENERATIVE  ORGANS 


and  the  thighs.  It  consists  of  four  bones — two  ossa 
innominata , the  sacrum,  and  the  coccyx.  These  are  so 


Fig.  2. — Female  pelvis  with  ligaments,  viewed  from  above  (Dickinson). 


Fig.  3. — Female  pelvis  with  ligaments,  viewed  from  below  (Dickinson). 


united  that  they  form  two  cavities — a greater  or  upper, 
or  false  pelvis,  a smaller  or  lower,  or  true  pelvis. 


THE  BONY  PEL  VIS 


23 


The  innominate  bones  flare  outward  like  flanges,  and 
leave  a space  in  front  which  is  filled  out  by  the  abdom- 
inal muscles,  and  behind,  above  the  sacrum,  the  spinal 
column  completes  the  false  pelvis.  The  false  pelvis  is 


Fig.  4. — Female  pelvis  showing  through  torso.  The  uterus  and  adnexa  are 
indicated  in  white. 


like  a flat  funnel,  and  has  the  function  of  directing  bodies 
in  the  abdomen  into  the  true  pelvis.  The  broad  flanging 
ossa  innominata,  with  the  abdominal  wall,  support  the 
abdominal  contents. 


24  ANATOMY  OF  FEMALE  GENERATIVE  ORGANS 


The  true  or  small  pelvis  is  just  below  the  large  pelvis; 
behind,  it  is  made  up  of  the  sacrum  and  the  coccyx;  at 
the  sides,  by  the  innominate  bones;  and  in  front,  by  the 
rami  of  the  innominate  bones.  In  front  it  is  only  2 
inches  high,  but  behind  it  is  6 inches.  The  bony  pelvis 
is  exceedingly  irregular  in  outline,  having  many  notches, 
and  several  openings  through  which  various  structures — 
muscles,  nerves,  blood-vessels,  etc. — pass. 

In  general,  the  shape  of  the  cavity  of  the  true  pelvis 
is  that  of  an  elbow  of  stovepipe.  Where  the  true  and 
false  pelves  join  there  is  a more  or  less  marked  rim. 
This  place  is  called  the  inlet,  brim,  or  upper  strait,  the 


pelvis  being  narrower  here  (Figs.  2,  5).  At  the  lower 
end  of  the  true  pelvis  is  the  outlet  (Figs.  3,6).  The  inlet 
is  shaped  like  a flattened  heart;  the  outlet,  an  antero- 
posterior ellipse,  so  that  an  ovoid  body  like  the  baby’s 
head,  passing  through  the  inlet  in  the  transverse  diam- 
eter, in  order  to  escape  from  the  outlet  must  turn  its 
long  diameter  to  correspond  with  the  long  diameter  of 
the  outlet  (Figs.  7,  8).  This  occurs  during  labor  and  is 
called  “rotation.” 

Since  the  cavity  of  the  pelvis  is  curved — a bent  canal 
-the  head  must  slide  along  it,  taking  a curved  course; 


THE  BONY  PEL  VIS 


25 


and  since  the  anterior  part  of  the  curve  is  shorter  than 
the  posterior,  the  part  of  the  head  lying  behind  will  have 


Fig.  7. — Head  of  fetus  at  the  inlet  of  the  pelvis.  Long  diameter  of  head  lies 
transversely. 

to  travel  a greater  distance  than  the  part  lying  in  front. 
These  are  the  things  which  the  doctor  must  consider 
when  he  studies  the  mechanism  of  labor. 


Fig.  8. — Head  of  fetus  at  the  outlet  of  the  pelvis.  Long  diameter  of  head  lies 
anteroposteriorly,  ready  to  escape  from  pelvis. 


The  pelvis  is  set  into  the  body  in  such  a way  that 
when  the  woman  is  standing  not  all  the  weight  of  the 


26  ANATOMY  OF  FEMALE  GENERATIVE  ORGANS 


abdominal  viscera  is  forced  down  into  its  cavity:  part 
is  borne  by  the  abdominal  wall  and  pubis.  When  a 
woman  constricts  the  abdomen  in  any  way,  as  by  a 
corset  or  a girdle,  the  viscera  are  forced  downward, 
and  since  the  false  pelvis  is  a funnel  leading  into  the 
true  pelvis,  the  organs  here  are  pressed  down,  and 
this  may  bring  about  prolapse  of  the  uterus,  blad- 
der, etc.  (See  Fig.  36.) 


Fig.  9. — Normal  pelvis.  Inlet  in  solid  color. 


The  pubes  or  symphysis  pubis  is  the  anterior  junction 
of  the  two  innominate  bones.  It  is  covered  by  a thick 
pad  of  fat,  the  mons  veneris,  and  is  strongly  hirsute  in 
most  women.  The  pelves  of  two  women  are  never  ex- 
actly alike.  Not  one  pelvis  in  20,000  is  exactly  symmet- 
ric. There  are  characteristics  in  pelves  as  regards  race, 
age,  environment,  occupation,  and  disease. 

Varieties  of  Pelves. — In  general,  there  are  four  va- 
rieties of  pelves — large,  small,  flattened,  and  distorted. 


THE  BONY  PELVIS 


27 


Finally,  there  are  all  sorts  of  combinations  of  these. 
A description  of  the  various  forms  of  pelves  would  fill 


Fig.  10. 


Fig.  12.  Fig.  13. 

Figs.  10-13. — Fig.  10.  Flat  pelvis.  Fig.  11.  Generally  contracted  pelvis. 
Fig.  12.  Generally  contracted  and  flat  pelvis.  Fig.  13.  Osteomalacic  pelvis.  The 
inlet  in  each  case  is  shown  in  solid  color.  All  were  photographed  to  same  scale. 

several  volumes,  and  cannot  be  given  here,  but  pictures 
of  a few  of  the  most  marked  deformities  are  presented 
(Figs.  10-13).  The  importance  of  deformed  pelves  is 


28  ANATOMY  OF  FEMALE  GENET  AT/VE  ORGANS 


great.  If  a pelvis  is  too  large,  the  child  may  be  forced 
through  too  quickly  and  tear  the  Soft  parts,  or  may  come 
in  anomalous  positions.  If  the  pelvis  is  too  small,  the 
mechanical  disproportion  between  the  size  of  the  pelvis 
and  of  the  baby  may  make  the  delivery  of  the  latter  im- 
possible, or  so  difficult  as  to  endanger  its  life  or  that  of 
its  mother.  The  same  may  be  said  of  the  other  forms 
of  contracted  pelvis.  Everything  depends  on  the  kind 
of  contraction  and  its  degree.  A large  woman  seldom 
has  a small  pelvis;  a very  small  woman  seldom  has  a 
large  pelvis. 

The  Soft  Parts.  -The  pelvis  is  lined  and  covered 
with  soft  tissues,  some  of  which  act  simply  as  fillers; 
others  are  muscles  for  various  working  functions.  Then 
there  are  special  organs,  as  the  bladder,  uterus,  vagina, 
rectum,  and  finally  there  are  the  blood-vessels  and 
nerves. 

The  large  pelvis  is  lined  with  muscles,  and  is  completed 
in  front  by  the  abdominal  muscles.  These  serve  to  in- 
crease the  funnel  shape  and  to  support  somewhat  the 
abdominal  contents.  The  small  pelvis  has  few  muscles, 
but  many  important  organs,  vessels,  nerves,  etc. 

The  Uterus. — This  organ  (Figs.  14,  15)  occupies 
the  middle  of  the  pelvis,  being  suspended  in  the  con- 
nective tissue  and  peritoneum  from  the  walls  of  the 
pelvis.  It  is  a flattened,  pear-shaped  body,  2\  inches 
long,  ii  inches  wide,  I inch  thick,  and  weighs  from  2 to 
2i  ounces.  It  is  a firm  organ,  but  when  pregnant  it 
grows  very  soft  and  increases  enormously  in  size  and 
capacity.  It  has  two  parts — the  fundus  and  the 
cervix.  The  cavity  of  the  uterus  is  usually  closed  by 
apposition  of  the  walls;  it  is  long,  narrow,  and  flattened. 
The  cervix  has  a little  round  opening  called  the  os, 
through  which  the  uterine  secretions,  the  menstrual 
blood,  during  labor  the  ovum,  and  during  the  puer- 


THE  SOFT  PARTS 


29 


perium  the  lochial  discharges,  pass.  In  virgins  it  is  a 
round  opening;  in  women  who  have  had  children,  a 
transverse  slit. 

The  uterus  is  attached  at  the  middle  of  the  cervix  to 
the  vagina , a sheath  4 inches  long,  terminating  at  an 


Fig.  14. — Section  showing  bladder,  uterus,  and  rectum.  Red  line  indicates 
the  peritoneum. 


opening  in  the  skin  called  the  vulva.  The  vagina  is  a 
very  elastic  tube  and  lies  between  the  bladder  and  the 
rectum.  In  ordinary  conditions  it  will  admit  one  or 
two  fingers,  but  during  labor  it  stretches  to  4 or  5 inches 
in  diameter.  The  uterus  has,  leading  outward  from 
its  upper  corners,  two  tubes — the  Fallopian  tubes.  These 


30  ANATOMY  OF  FEMALE  GENERATIVE  ORGANS 


are  about  the  size  of  a crow’s  quill,  are  tortuous,  growing 
larger  as  they  leave  the  uterus,  to  terminate  in  trumpet- 
shaped ends  fringed  with  delicate  streamers  called 
JlmbricB.  The  canal  of  the  tube  likewise  grows  larger 
after  it  leaves  the  uterus.  Thus  there  is  a free  passage 
through  the  vulva,  the  vagina,  the  os,  the  cervix,  the 
uterine  body,  and  the  tubes  to  the  fimbriated  ends  open- 
ing out  into  the  peritoneal  cavity. 

The  organs  just  named  are  composed  of  walls  more 
or  less  thick,  made  up  of  muscle  and  connective  tissue, 
lined  throughout  with  mucous  membrane,  and  covered 


Fig.  15. — Uterus,  tubes,  and  ovaries.  On  the  right  the  ovary  and  tube  have 
been  laid  open 


by  peritoneum  for  part  of  the  distance.  The  mucous 
membrane  varies  in  quality  in  different  portions  of  the 
canal,  according  to  the  function  required  of  the  part: 
at  the  vulva  it  is  delicate  and  very  sensitive;  in  the 
vagina,  rough  and  strong;  in  the  cervix  and  uterus,  very 
vascular  and  velvety.  In  the  uterus  and  tubes  the  epi- 
thelium is  covered  with  a microscopic  down  which  has 
the  function  of  automatic  waving  like  a field  of  wheat 
in  the  wind,  thus  propelling  toward  the  outlet  any  object 
lying  on  the  surface. 

The  layers  of  peritoneum  covering  the  anterior  and 
posterior  walls  of  the  uterus  meet  at  the  sides  of  the  organ 


THE  EXTERNAL  GENITALS 


31 


and  form  flattened  bands  stretching  to  the  side  walls  of 
the  pelvis,  containing  vessels,  nerves,  and  a little  fat,  and 
called  the  broad  ligaments.  These  have  great  import- 
ance in  obstetrics.  Attached  to  the  posterior  side  of 
each  broad  ligament,  and  connected  with  one  of  the  fim- 
briae or  streamers  of  the  Fallopian  tube,  is  a little  body, 
in  shape  and  size  like  an  almond,  hard,  fibrous,  and 
dimpled — this  is  the  ovary. 

The  Bladder.  -This  organ  (Fig.  14)  lies  in  front  of 
the  uterus,  behind  the  pubis.  From  the  bladder,  lying 
along  the  side  of  the  cervix,  the  ureters  run  up  out  of 
the  pelvis  to  the  kidneys.  In  front  of  the  vagina,  just 
behind  and  below  the  pubis,  lies  the  urethra , a small  tube 
about  the  size  of  a lead-pencil,  leading  from  the  bladder 
to  open  in  the  upper  part  of  the  vulva  The  bladder 
empties  itself  through  the  urethra.  The  urethra  ends  in 
the  vestibule  of  the  vulva,  the  opening  being  called  the 
meatus  urinarius. 

The  Rectum. — Behind  the  uterus,  to  the  left  side,  lies 
the  rectum  (Fig.  14),  or  the  last  portion  of  the  intestinal 
canal.  It  is  continuous  with  the  sigmoid  flexure  of  the 
colon  above,  and  terminates  at  the  skin  below  in  the 
anus.  The  rectum  is  a large,  slightly  convoluted  tube, 
of  much  strength  and  great  distensibility.  Its  course 
upward  and  to  the  left  is  noteworthy.  A rectal  tube  in 
passing  should  take  these  directions. 

The  Peritoneum.  -The  pelvic  peritoneum,  a thin,  glis- 
tening, veil-like  structure,  a part  of  the  general  abdominal 
peritoneum,  comes  down  from  above  and  covers  the  top 
of  the  bladder,  the  uterus,  the  tubes,  and  the  rectum. 
Thus  a woman  who  has  an  infection  of  the  genital  organs 
may  develop  general  peritonitis  by  simple  continuity  of 
surface.  (See  red  line  in  Fig.  14.) 

The  External  Genitals. — The  outlet  of  the  bony 
pelvis  is  filled  in  by  muscles  and  covered  by  skin.  At 


32  ANATOMY  OF  FEMALE  GENE RATIVE  ORGANS 

the  sides  of  the  lower  end  of  the  trunk  the  thighs  are 
inserted,  and  between  the  two  thighs  lies  a space  called 
the  genital  crease  or  fold.  This  area  extends  anteriorly 
to  the  pubis  and  posteriorly  to  the  sacrum,  and  when  the 
thighs  are  separated  it  presents  a small  extent  of  sur- 
face, but  when  the  legs  lie  close  together  the  space  is 
reduced  to  a deep  groove.  The  front  part  of  this  region 
is  occupied  by  the  vulva,  or  external  genitalia,  the  back 
part  by  the  anus,  while  between  these  two  is  a small 
body  composed  of  skin  and  muscle,  called  the  perineum. 

The  Vulva  (Fig.  16). 
-This  is  made  up  of 
two  more  or  less  heavy 
lips  or  labia — the  labia 
majora — composed  of 
skin  and  fat,  covered 
with  hair,  and  abun- 
dantly supplied  with 
sebaceous  glands.  The 
labia  terminate  anterior- 
ly in  the  mons  veneris , 
a pad  of  fat  covering 
the  pubis.  Behind  they 
spread  out  in  the  peri- 
neum. Beneath  and  be- 
tween the  labia  majora 
are  two  smaller  labia, 
called,  in  contradistinc- 
tion, the  labia  minora, 
made  up  of  thin  skin 
and  mucous  membrane. 
Anteriorly  the  labia  minora  meet  and  form  a hood, 
which  covers  a little  erectile  organ,  the  clitoris;  pos- 
teriorly they  disappear  at  the  sides  of  the  outlet  of  the 
vagina.  The  clitoris  is  attached  to  the  under  surface  of 


THE  EXTERNAL  GENITALS 


33 


the  pubis,  and  is  a little  elongated  mass  of  blood-vessels 
covered  by  mucous  membrane.  It  is  protected  by  the 
hood  aforementioned.  It  is  very  sensitive.  Under  the 
hood,  smegma,  a whitish,  flaky  material,  being  the  dried 
secretions,  is  likely  to  collect  and  form  a lodging  place 
for  germs,  an  important  point  for  the  nurse  to  know. 
It  is  a serious  error  of  technic  for  the  nurse  to  leave 
smegma  under  the  hood  of  the  clitoris  in  her  prepara- 
tion  of  the  patient  for  labor  or  operation. 

Below  the  clitoris  is  a flat,  triangular  area,  covered  by 
mucous  membrane — the  vestibule — at  the  lower  part  of 
which  are  two  little  raised  ridges  with  an  opening 
between  them — the  mouth  of  the  urethra,  the  meatus 
urinarius — through  which  the  urine  is  voided. 

Below  this  opening  is  the  outlet  of  the  vagina,  sur- 
rounded by  a fringe  of  mucous  membrane  called  the 
hymen.  The  hymen  lies  at  the  opening  of  the  junction 
of  the  vagina  with  the  vulva,  is  a thin,  circular  structure, 
and  tears  when  the  child  pushes  through  if  it  has  not 
been  torn  during  the  first  conjugal  relation.  The  shape 
of  the  hymen  varies  in  different  women:  some  have 
hardly  any;  in  others  it  covers  the  opening  of  the  vagina 
and  may  have  only  a pin-hole  perforation,  or,  in  rare 
cases,  no  opening  at  all.  It  may  be  sickle-shaped  or 
have  several  perforations. 

Between  the  hymen  and  the  terminations  of  the  two 
labia  majora  in  the  perineum  is  a boat-shaped  depression 
— the  fossa  navicularis;  and  at  the  junction  of  the  two 
labia  majora  is  the  posterior  commissure  or  fourchet , a 
band  of  skin  forming  part  of  the  fossa  navicularis. 

The  Perineum. — The  perineum  lies  between  the 
vagina  and  the  anus.  It  is  composed  of  skin,  connective 
tissue,  and  muscle,  separating  the  vulva  from  the  anus, 
Since  the  vagina  leads  forward  and  the  anus  backward, 
there  is  a triangular  space  between  their  outer  termina- 

3 


34  ANATOMY  OF  FEMALE  GENERATIVE  ORGANS 

tions.  This  space  is  filled  up  by  the  triangular  perinea } 
body.  During  labor,  when  the  head  comes  down  through 
the  vagina,  it  stretches  the  vulva  open  and  pushes  the 
perineum  backward  against  the  anus  and  rectum,  flatten- 
ing it  out.  During  the  passage  of  the  child  the  perineum 
is  often  torn,  which  is  unfortunate,  as  the  integrity  of 
the  tissues  and  organs  above  it  is  partly  dependent  upon 
this  structure.  Of  more  importance  are  the  tears  of 
the  pelvic  floor,  which  are  hard  to  find  and  are  usually 
overlooked  by  the  general  practitioner.  When  the  peri- 
neum is  torn  deeply  the  anus  and  rectum  may  be  laid 
open.  This  is  a sad  accident,  as  the  woman  may  thus 
lose  control  of  the  bowel.  Immediate  repair  of  all 
injuries  should  be  made. 

The  Anus. — About  ij  inches  below  the  fourchet  is  a 
deep,  pigmented,  puckered  opening — the  anus.  This 
is  the  outlet  of  the  rectum.  The  skin  of  the  perineum 
dips  down  into  the  anus  a short  distance  to  meet  the 
mucous  membrane  of  the  rectum.  Underneath  the 
skin  and  mucous  membrane  lies  a network  of  large  veins. 
If  these  veins  become  overdistended  with  blood,  as 
occurs  sometimes  during  labor,  they  form  very  painful 
masses,  called  hemorrhoids , or  piles. 

The  anus  is  held  closed  by  a circular  muscle,  in 
size  and  shape  not  unlike  a broad  wedding  ring — 
the  sphincter  ani.  This  muscle  controls  the  passage  of 
feces  and  gas.  It  is  occasionally  torn  during  delivery, 
the  so-called  “complete  laceration,”  and  if  not  success- 
fully repaired  allows  the  rectal  contents  to  escape  un- 
hindered. This  condemns  the  patient  to  social  ostra- 
cism, and  the  accoucheur,  therefore,  bends  every  effort 
to  preserve  this  small  but  important  muscle. 


THE  BREASTS 


35 


THE  BREASTS 

The  breasts  belong  to  the  genitalia,  since  they  take  an 
important  part  in  generation.  They  are  located  over  the 
anterior  part  of  the  chest,  but  in  very  rare  cases  may  be 
located  in  other  parts  of  the  body  or  be  more  than  two 
in  number.  One  woman  had  five— on  the  chest,  back, 
side,  and  thigh.  They  are  glands  modified  from  skin 
glands  to  perform  a different  function,  and  belong  to  the 
compound  racemose  clustering  type.  Each  breast  is 
made  up  of  lobes;  these  are  divided  into  lobules,  and 
each  lobule  is  composed  of  minute  cells  or  acini.  A 
tube  from  each  lobule  leads 
into  a main  canal,  which 
opens  on  the  surface  of  the 
nipple  as  a fine  duct.  These 
tubes  collect  the  milk  from 
the  acini  and  discharge  it 
through  the  nipple  (Fig. 

1 7) . Before  opening  on  the 
nipple  each  duct  enlarges, 
forming  a spindle-shaped 
cavity,  called  the  sinus  lac- 
tiferus. 

Each  lobe  of  the  breast 
may  be  likened  to  a bunch 
of  grapes,  and  the  milk- 
ducts  to  the  stems.  Each 
breast  has  from  fifteen  to 
twenty  lobes,  and  the  ducts 
leading  from  these  lobes 
are  all  brought  together  in  f ig.  17. — Semidiagrammatic  section  of 
the  nipple.  Between  the  a functionating  female  breast. 

lobes  or  bunches  the  irregu- 
lar spaces  are  filled  with  fat  and  connective  tissue. 
The  gland  rests  on  a bed  of  connective  tissue,  which 


36  ANATOMY  OF  FEMALE  GENE  FA  FIVE  OF  G A NS 

separates  it  from  the  chest  muscles,  ribs,  and  inter- 
costal spaces.  The  outside  of  the  gland  is  covered  by 
skin  which  is  more  delicate  than  that  of  the  remainder 
of  the  body,  and  allows  the  blue  veins  to  show  through. 
The  nipple  is  raised  \ to  \ inch  above  the  surface.  In 
brunets  it  is  darkly  pigmented,  in  blondes  it  is  pink. 
At  its  base  is  a circular  area,  likewise  pink  or  pigmented 
-The  areola.  This  area  contains  small  nodules,  the 
tubercles  of  Montgomery , which  grow  more  prominent 
during  pregnancy.  These  are  little  glands,  and  occa- 
sionally a few  drops  of  milk  may  be  squeezed  from  them. 
They  also  are  liable  to  infection. 


CHAPTER  II 


PHYSIOLOGY 

THE  FUNCTION  OF  REPRODUCTION 

Ovulation. — The  main  function  of  the  ovary  is  the 
production  of  ova  or  eggs.  It  probably  possesses  other 
functions  as  a blood  and  nerve  regulator,  but  we  do 
not  understand  them.  It  elaborates  an  internal  secre- 
tion and  this  affects  other  organs  of  the  body,  particularly 
the  uterus.  The  ovary  of  a newborn  child  contains 
from  20,000  to  50,000  ova.  These  ova  remain  quiescent 
until  the  girl  is  about  eight  or  ten  years  old,  when 
they  begin  to  develop  to  maturity  and  are  periodically 
expelled  from  the  ovary.  This  function  is  called 
ovulation.  Ovulation  is  the  ripening  of  an  ovum  and  its 
discharge  from  the  ovary.  The  greatest  activity  of  the 
ovary  occurs  at  the  time  of  puberty — that  is,  from  the 
twelfth  to  the  sixteenth  year. 

Puberty. — This  is  the  period  at  which  the  individual 
becomes  capable  of  reproduction.  It  begins  in  males 
from  the  fourteenth  to  the  seventeenth  year;  in  females, 
from  the  twelfth  to  the  fifteenth  year.  The  changes 
occur  more  rapidly  and  are  more  marked  in  the  female. 
They  are  both  physical  and  psychical.  The  body 
develops  quickly  and  the  breasts  enlarge.  The  external 
genitals  increase  in  size  and  become  covered  with  hair. 

The  mind  changes  in  the  three  parts : the  will,  the  in- 
tellect, and  the  emotions.  The  will  becomes  uncertain 
and  hysteric  manifestations  are  common  The  emo- 
tions develop,  together  with  a sense  of  modesty. 

37 


PHYSIOLOGY 


38 


This  transformation  is  the  outward  expression  of  the 
changes  going  on  in  the  internal  organs  of  generation — 
the  ovaries,  uterus,  and  tubes.  Though  ability  to  repro- 
duce is  present  at  puberty,  fitness  is  not.  The  best  year 
for  the  woman’s  first  child  is  about  the  twenty- third,  but 
children  have  been  born  to  mothers  of  nine  and  of  sixty- 
two  years.  The  advent  of  puberty  is  marked  by  the 
inauguration  of  a new  function — menstruation. 

Menstruation  may  be  defined  as  the  appearance, 
monthly,  of  a discharge  of  blood  from  the  genitals, 
attended  by  general  symptoms  of  malaise  and  disturbed 
nerve  equilibrium  and  local  symptoms  of  congestion 
of  the  uterus  and  neighboring  organs.  It  is  one  of  the 


Fig.  18  — Three  weeks’  ovum  in  sac  (natural  size).  Note  the  fine  shaggy  coat, 
the  threadlike  villi. 

external  indications  of  the  changes  in  the  ovary  produced 
by  ovulation  and  the  stimulation  of  the  whole  nervous 
system  which  this  function  causes.  The  uterus  presents 
most  marked  changes  during  menstruation.  It  is  en- 
larged, softened,  and  turgid  with  blood.  The  mucous 
membrane  is  much  thickened,  soft,  presenting  a deep-red, 
velvety  appearance.  Blood  oozes  from  the  surface, 
mixes  with  the  natural,  but  augmented  secretions 
from  the  whole  genital  tract,  and  altered  in  color  and 
odor,  escapes  from  the  vulva.  After  from  three  to  seven 
days  the  discharge  ceases,  the  tumefaction  of  the 
uterus  and  mucosa  disappears,  and  the  latter  has  resumed 
its  smooth,  pink  appearance. 


THE  FUNCTION  OF  REPRODUCTION 


39 


Menstruation  presents  many  peculiarities  as  to  fre- 
quency, duration,  amount,  and  quality  in  different 
women.  In  some  women  it  recurs  every  twenty-one 
days;  in  others,  every  twenty-eight  or  thirty  days.  It 
lasts  from  three  to  seven  days — usually  five  days.  In 
some  races,  as  the  Orientals,  the  first  menses  appear  at 
the  age  of  thirteen;  in  others,  as  the  Europeans,  at  four- 
teen and  fifteen  years.  Normally  there  is  no  actual 


Fig.  19. — Six  weeks’  ovum  in  sac  (natural  size).  The  little  fetus,  about  the  size 
and  shape  of  a kidney  bean,  is  inside  the  translucent  sac. 


pain,  though  many  women  do  suffer  some  soreness  and 
distress.  Women  are  more  nervous  and  irritable  during 
the  period,  more  subject  to  cold,  headaches,  etc.  Some 
women  experience  about  midway  between  the  periods 
symptoms  resembling  those  of  the  menses,  but  without 
any  bloody  discharge. 

Ovulation  usually  occurs  every  month  at  the  time  of 
menstruation,  and  the  ovum  is  expelled  from  the  ovary, 
passes  down  the  Fallopian  tube  through  the  uterus,  and 


40 


PHYSIOLOGY 


is  lost  with  the  menstrual  blood.  The  changes  in  the 
mucosa  of  the  uterus  were  designed  to  prepare  it  for  the 
reception  of  the  ovum,  in  case  it  should  be  made  fertile 
by  union  with  a male  element,  and  to  favor  its  attach- 
ment to  the  uterus  and  its  further  development  there. 
This  preparation  of  the  mucous  membrane  of  the  uterus 
is  called  nest-building. 

Conception. — The  union  of  the  female  element,  the 
ovum,  with  the  male  element,  the  spermatozoid,  is  called 


3 4 

Fig.  20. — Early  human  embryos,  all  enlarged  about  two  and  a half  times:  i, 
Second  week;  2,  third  week;  3,  fourth  week;  4,  fifth  week;  am,  amnion;  uv, 
umbilical  or  vitelline  vesicle;  als,  allantoic  or  abdominal  stalk;  c,  brain-vesicles; 
h,  heart;  0,  optic  vesicle;  ot,  otic  vesicle;  ol,  olfactory  pit;  s,  somites;  cd,  caudal 
process  (His). 


fertilization,  fecundation,  impregnation,  or  conception. 
This  union  may  occur  in  the  tube  or  in  the  uterus — pre- 
sumably in  the  tube.  After  it  occurs,  and  only  then,  the 
ovum  thus  fertilized  readily  becomes  attached  to  the 
velvety  uterine  mucosa.  No  menstruation  occurs,  and 
the  mucosa  undergoes  the  changes  incident  to  pregnancy. 
The  woman  is  now  pregnant,  and  mighty  changes  are 
inaugurated  in  the  little  ovum  clinging  weakly  to  the 


THE  FUNCTION  OF  REPRODUCTION 


41 


mucous  membrane  of  the  uterus,  and  also  in  nearly  every 
part  of  the  woman’s  body. 

At  the  very  beginning  the  ovum  is  a tiny  vesicle, 
hardly  visible  to  the  naked  eye;  in  two  weeks  it  has 
grown  to  the  size  of  a large  pea,  and  in  four  weeks  to  that 
of  a walnut.  It  is  a sac  covered  with  a shaggy  coat  of  deli- 
cate branched  threads  called  villi.  (See  Fig.  18.)  These 
villi  dip  into  the  uterine  surface  and  bring  nutrition  and 


Fig.  21. — Two  months’  pregnancy,  showing  the  fetus  in  the  uterus  (one-half 
natural  size). 

oxygen  from  the  mother  to  the  child.  At  this  time  the 
child  is  hardly  recognizable  as  such.  At  eight  weeks  the 
ovum  has  attained  the  size  of  a lemon,  and  the  surface 
has  become  differentiated  into  a protecting  part  and  a 
nutritive  part — the  placenta.  The  villi  at  one  portion 
of  the  ovum  have  grown  enormously,  are  intertwined  into 
a compact  mass  attached  to  the  uterus,  supplied  with 
blood  from  the  maternal  circulation,  and  communicating 


42 


PHYSIOLOGY 


by  means  of  the  umbilical  cord  with  the  body  of  the  child. 
The  mass  of  intertwined  villi  is  called  the  placenta.  The 
rest  of  the  covering  of  the  ovum  not  occupied  by  the 
placenta  is  simply  the  membranes,  serving  to  contain  a 
fluid  in  which  the  child  swims,  and  shutting  the  interior 
off  from  the  outside  world.  The  fluid  is  called  liquor 
amnii.  The  child  at  this  time  is  completely  formed;  it  is 


Fig.  22. — Fetuses  of  the  second,  third,  and  fourth  months  of  pregnancy  (three- 
fifths  natural  size). 


about  3 inches  long,  the  head  being  nearly  as  large  as 
the  rest  of  the  body. 

At  sixteen  weeks  the  ovum  is  about  as  large  as  a 
man’s  two  fists,  and  presents  in  miniature  all  the  appear- 
ances of  the  ovum  at  term.  At  nine  months,  or  “term,” 
or  “full  time,”  the  completion  of  pregnancy,  the  uterus 
resembles  in  size  and  shape  a watermelon.  The  child 
lies  in  it,  usually  with  head  down,  completely  formed, 


THE  FUNCTION  OF  REPRODUCTION 


43 


ready  for  delivery.  (See  Frontispiece  and  Plate  II.) 
The  placenta  is  well  developed,  lying  usually  on  one  side 
of  the  uterus,  far  from  the  internal  os.  The  umbilical 
cord  connects  the  placenta  with  the  child ; it  is  as  thick  as 
the  little  finger  and  much  twisted.  The  liquor  amnii  is 
usually  about  enough  to  fill  up  the  spaces  left  between  the 
body  of  the  child  and  the  uterine  walls  lying  against  it. 

The  head  o f the  fetus  throughout  pregnancy  is  mark- 
edly developed,  and  during  delivery  usually  gives  more 
trouble  than  the  body.  The  vault  of  the  skull  is  made 
up  of  four  bones : at  the  sides  are  the  parietal  bones ; at 
the  front,  the  frontal;  at  the  back,  the  occipital  bone. 
The  bones  forming  the  vault  of  the  cranium  are  not 
joined  fast  together  as  in  the  adult,  but  are  connected 
by  soft  membranes,  leaving  sutures  and  fontanels  at  their 
contiguous  borders  (Figs.  23,  24).  Between  the  parietal 
bones  is  the  sagittal  suture;  between  the  parietal  and 
occipital  bones,  the  lambdoid  suture;  between  the  parie- 
tal and  frontal  bones,  the  coronary,  and  in  the  frontal 
bone,  the  frontal  suture.  Where  the  two  parts  of  the 
frontal  and  the  two  parietal  bones  meet  lies  an  open,  four- 
cornered,  lozenge-shaped  space  filled  in  by  membrane, 
called  the  anterior  or  large  fontanel , and  where  the  parietal 
and  occipital  bones  meet  lies  the  posterior  or  small  fon- 
tanel. This  is  really  no  opening,  but  the  meeting  of 
three  sutures.  This  arrangement  of  bones,  sutures,  and 
fontanels  is  designed  to  allow  the  head  to  mold  and  adapt 
itself  to  the  mother’s  pelvis  during  labor,  so  that  it  may 
pass  through  with  the  least  resistance  and  injury  to  both 
head  and  pelvis.  After  a prolonged  labor  in  a primipara 
the  head  is  sometimes  drawn  out  almost  to  a sausage 
shape.  Should  the  child  have  been  delivered  with  the 
face  first,  a corresponding  molding  takes  place  and  the 
head  assumes  a different  shape.  During  the  first  days 
after  labor  the  bones  resume  their  proper  relation  to  each 


44 


PHYSIOLOGY 


Fig.  23. — Fetal  skull  at  term,  showing  fontanels.  Side  view,  showing  the 
coronary  suture  to  left;  the  lambdoid  below  and  to  the  right;  the  lateral  suture 
below  and  in  the  center  (Dickinson). 


Fig.  24. — Fetal  skull  at  term.  Seen  from  above  and  showing  the  small 
fontanel  at  upper  pole  of  figure;  the  large  or  anterior  fontanel  below;  the  sagittal 
suture  in  the  center;  the  coronary  suture  at  the  sides  of  the  large  fontanel;  the 
frontal  suture  leading  down  from  the  large  fontanel  (Dickinson). 


THE  FUNCTION  OF  REPRODUCTION  45 

other,  the  overlapping  sutures  broaden,  the  bones  them- 
selves straighten  out,  and  the  deformity,  which  may  have 
alarmed  the  mother,  disappears. 

The  child  in  the  uterus  lies  folded  together : the  legs  are 
bent  on  the  thighs,  the  thighs  on  the  belly,  the  forearm 
on  the  arm,  the  arms  across  the  chest,  the  head  bent 
down  over  the  breast  (Figs.  25,  26).  There  are  not  in- 
frequent changes  in  the  attitude  of  the  child,  for  ex- 


Fig.  25. — Side  view  of  fetus,  showing  Fig.  26. — Front  view  of  fetus,  showing 
the  attitude  it  holds  in  the  uterus.  the  attitude  it  holds  in  the  uterus. 


ample,  the  chin  may  leave  the  chest  and  be  stretched 
upward,  in  so-called  face  presentation,  or  the  arms 
may  leave  the  chest  and  prolapse  before  the  head. 

At  term  the  infant  weighs  about  7 pounds;  the  pla- 
centa, 1 1 pounds,  and  there  is  about  1 quart  of  liquor 
amnii.  The  average  weight  for  the  newborn  girl  is 
7 pounds;  for  the  boy,  7 } pounds.  The  boys,  therefore, 
give  more  trouble  in  delivery,  and  consequently  more  of 


46 


PHYSIOLOGY 


them  die.  The  first  child  is  usually  smaller  than  sub- 
sequent children;  io-pound  babies  are  rare,  and  chil- 
dren weighing  over  12  pounds  at  birth  are  very  excep- 
tional indeed. 

THE  PHYSIOLOGY  OF  THE  FETUS  IN  THE  UTERUS 

The  general  metabolism  of  the  child  is  similar  to  that 
of  the  adult.  The  fetus  has,  however,  no  respiratory 
function,  very  insignificant  digestive  action,  and  little 
skin  function,  since  these  are  hardly  necessary,  its  mother 
performing  them  for  it.  It  has  its  own  heat-producing 
and  regulating  mechanism,  as  is  shown  by  the  fact  that 
the  child’s  temperature  is  \ degree  higher  than  that  of 
its  mother. 

It  gets  oxygen  from  the  mother  through  the  placenta, 
also  water  and  food  prepared  for  assimilation.  A small 
portion  of  the  food  comes  from  the  liquor  amnii  which 
the  infant  swallows.  The  waste-products  from  the  child, 
and  the  carbon  dioxid  which  the  adult  exhales  from  the 
lungs,  in  the  infant  pass  through  the  placenta  to  the 
mother,  and  are  excreted  by  her  organs.  All  this  is 
accomplished  by  way  of  the  placenta. 

The  Placenta. — This  organ  resembles  a flat  cake.  The 
umbilical  cord  leading  from  the  child  is  inserted  on  one 
side,  while  the  other  is  attached  to  the  inner  surface  of 
the  uterus.  The  mother’s  blood  flows  in  and  around 
the  placenta.  After  the  child  is  delivered  the  placenta 
is  separated  from  the  wall  of  the  uterus  and  expelled. 
This  important  organ  is  made  up  of  a number  of  lobes, 
each  lobe  containing  a large  number  of  trees  of  chorionic 
villi.  A villus  is  a tiny,  fingerlike  filament  which  dips 
into  the  maternal  blood  in  the  placenta  and  through 
which  the  above-mentioned  changes  take  place.  A de- 
scription of  the  villi  would  take  too  many  pages.  Each 
nurse  should  shred  or  tease  a piece  of  placenta  with  a 


PLATE  J 


Diagrams  to  show  the  relations  of  the  maternal  and  fetal  circulations. 


PHYSIOLOGY  OF  THE  FETUS  IN  THE  UTERUS  47 

pin,  and  float  it  in  a glass  of  water,  when  the  fine  ele- 
ments or  villi  will  be  prettily  shown  (Fig.  27). 

The  blood  of  the  child  flows  through  the  vessels  of 
the  cord  to  the  placenta,  then  through  the  inside  of  the 
villi,  and  the  villi  dip  into  the  maternal  blood,  and  since 
there  is  no  direct  connection  between  the  blood  of  the 
fetus  and  that  of  the  mother,  the  changes  must  occur  by 
osmosis  and  the  vital  cellular  activity  of  the  wall  of  the 
villus.  Water,  oxygen,  and 
food  go  to  the  fetus  through 
the  villus;  carbon  dioxid  and 
waste-products  go  from  the 
fetus  to  the  mother  in  the 
same  way.  The  villi,  there- 
fore, are  like  the  roots  of  a 
tree,  drawing  water  and  sus- 
tenance from  the  ground.  The 
sap  of  the  tree  within  the 
roots  does  not  get  into  the 
ground,  yet  water  and  susten- 
ance get  into  the  sap  through 
the  outer  covering  of  the  roots. 

The  blood  of  the  fetus,  laden 
with  carbon  dioxid  and  waste 
materials,  goes  to  the  placenta 
through  the  umbilical  arter- 
ies, and  returns  to  the  child 
by  the  umbilical  vein,  carrying  oxygen,  water,  and  food. 
(See  Plate  I) . The  blood  of  the  umbilical  vein  is  red, 
while  that  in  the  arteries  is  venous,  or  dark,  which  is  the 
reverse  of  the  usual. 

The  liver  of  the  child  is  very  active,  and,  therefore, 
large.  It  reaches  half-way  to  the  navel.  The  stomach 
and  intestines  have  weak  digestive  power.  The  child 
drinks  the  liquor  amnii,  as  is  shown  by  the  lanugo  which 


Fig.  27. — A piece  of  placenta 
teased  and  hung  in  a glass  of 
water. 


48 


PHYSIOLOGY 


is  found  in  the  meconium.  The  kidneys  act  and  the 
urine  is  voided  into  the  liquor  amnii.  This  action  is 
very  small  indeed,  and  may  not  begin  until  labor  has 
begun. 

The  child  moves  about,  changing  from  uncomfortable 
positions  to  others.  It  sometimes  has  hiccup  and  it 
sucks  its  thumb  in  the  uterus,  and  tiny  respiratory  move- 
ments are  sometimes  observed.  The  hiccup  is  an  in- 
teresting phenomenon.  The  women  say  they  can  dis- 
tinguish regular  attacks  of  hiccups.  The  child  makes 
rhythmic,  jerky  movements,  recurring  about  eighteen  to 
the  minute.  Often  the  infant  stretches,  and  the  mother 
gets  to  know  its  habits,  which  may  correspond  with 
those  after  birth.  The  child  has  periods  of  rest  and 
activity.  Sometimes  the  activity  is  so  great  as  to  dis- 
turb the  mother’s  rest  and  require  treatment.  The  men- 
tal conditions  of  the  fetus  have  been  the  subject  of  much 
speculation.  While  the  child  suffers  pain  when  hurt,  the 
sensation  is  not  as  developed  during  birth  as  it  is  shortly 
after. 


CHAPTER  III 


PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

MATERNAL  CHANGES  IN  PREGNANCY 

The  development  of  a new  life  in  the  uterus,  the  per- 
formance of  the  new  function — reproduction — is  at- 
tended with  decided  changes  in  the  whole  being  of  the 
woman.  No  part  of  the  body  fails  to  feel  the  stimulus  of 
the  reproductive  function.  These  changes  are  divided 
into  two  classes:  first,  local  changes — those  found  in  the 
genitals  and  the  breasts;  second,  general  changes — those 
involving  the  rest  of  the  body. 

Local  Changes.- -The  uterus  in  the  virgin  state  is 
small,  weighing  about  2 ounces.  It  grows  during  preg- 
nancy to  a sac  so  large  that  it  reaches  almost  to  the 
ribs,  and  weighs,  when  empty,  about  2 pounds.  As  preg- 
nancy advances  the  walls  of  the  uterus  grow  thicker  and 
more  powerful,  the  muscle-fibers  become  stronger  and 
increase  in  number,  and  the  uterine  muscle  develops  the 
functions  of  contractility  and  retractility  to  a high 
degree.  The  uterus  grows  of  itself  faster  than  the  grow- 
ing ovum  distends  it,  and  when  the  child  is  ready  for 
delivery  the  uterus  is  a powerful  hollow  muscle.  It  ex- 
pels the  child  and  after-birth  with  great  force,  and 
gentleness  withal.  The  blood-vessels  also  increase  in 
size  and  number.  Some  of  the  veins  are  as  large  as  the 
finger,  especially  those  in  that  part  of  the  uterus  to 
which  the  placenta  is  attached.  The  lymphatics 
throughout  the  pelvis  are  also  enlarged.  The  vagina 
4 49 


50  PREGNANCY,  LABOR , AND  THE  PUERPERIUM 


and  vulva  become  softer,  more  dilatable,  and  there  is 
an  actual  increase  in  size.  All  these  changes  are  brought 
about  by  nature  in  preparation  of  the  parts  for  the  safe 
delivery  of  the  child. 

The  uterus  is  developed  into  a strong  muscular  engine, 
while  the  vagina  and  vulva  are  softened  and  prepared 
for  the  great  distention  they  will  suffer  when  the  child 
is  forced  through  them. 

The  breasts  enlarge  early  in  pregnancy:  sometimes 
there  are  a tingling  and  a sensation  of  fulness  and 


Fig.  28. — The  breast  in  pregnancy.  Brunet.  Shows  the  primary  areola  and  a 
marked  secondary  areola. 


weight  as  early  as  the  fifth  week.  The  nipple  enlarges 
and  becomes  more  erectile.  The  primary  areola  darkens 
by  the  deposit  of  pigment,  the  tubercles  of  Mont- 
gomery in  it  enlarge,  and  the  areola  is  puffy  and 
slightly  raised.  (See  Fig.  28.)  Later  in  pregnancy 
a little  clear  fluid  streaked  with  yellow  can  be  ex- 
pressed from  numerous  openings  on  the  nipple.  This 
is  called  colostrum.  Around  the  primary  areola  some- 
times a secondary  areola  forms.  The  secondary  areola 
is  commoner  in  brunets,  and  resembles  dusty  paper  with 
a sprinkling  of  water  drops.  This  pigmentation  of  the 


MATERNAL  CHANGES  IN  PREGNANCY 


51 


breasts  is  especially  marked  in  brunets,  and  in  negresses 
the  nipples  may  be  almost  black.  Light  purplish,  radi- 
ating lines  sometimes  appear  around  the  periphery  of  the 
breasts.  These  are  called  linea  or  striae  gravidarum,  are 
more  numerous  in  blondes,  and,  after  nursing  is  com- 
pleted, remain  as  fine,  white,  linear  scars.  Blue  veins 
often  show  through  the  skin,  which  is  a sign  of  good 
omen,  as  it  promises  a sufficient  milk  supply.  Sometimes 
the  breasts  grow  so  large  and  heavy  that  some  form  of 
artificial  support  is  necessary. 

General  Changes.  -Every  tissue  and  fiber  in  the 
woman’s  body  feels  the  impetus  of  pregnancy.  Mau- 
riceau  said  that  pregnancy  was  a disease  of  nine  months’ 
duration.  This  is  not  strictly  true,  though  many  women 
suffer  much  throughout  the  whole  period.  Many 
women  feel  best  while  pregnant,  and  some  are  perma- 
nently benefited.  Pregnancy  tests  the  integrity  of  every 
organ  in  the  body,  and  if  any  one  of  them  is  diseased 
the  fact  will  usually  be  brought  out. 

The  blood  is  increased  in  amount  in  the  last  months 
of  pregnancy  and  its  clotting  power  augmented,  nature 
thus  preparing  for  the  loss  of  blood  during  labor.  The 
heart  is  a little  enlarged ; the  veins  of  the  legs  are  usually 
more  or  less  varicose,  thus  forming  reservoirs  of  blood. 
The  thyroid  gland  in  the  neck,  the  spleen,  and  all  the 
blood-making  organs  increase  in  size  and  activity. 

The  lungs  are  pushed  upward  by  the  uterine  tumor, 
but  their  capacity  is  increased,  as  the  chest  is  actually 
broadened.  The  respiration  becomes  thoracic.  If  the 
uterus  is  over  distended,  it  pushes  the  abdominal  organs 
up  against  the  diaphragm,  interferes  with  the  action  of 
this  muscle,  and  thus  causes  great  difficulty  in  breathing. 

The  Urine. — The  total  quantity  of  urine  is  increased. 
The  specific  gravity  is  often  low.  Sugar  in  traces  is 
sometimes  present,  also  albumin  in  traces,  but  these  are 


52  PREGNANCY, \ LABOR,  AND  THE  PUERPERIUM 

always  significant,  and  the  patient  requires  close  obser- 
vation and  a physician’s  care.  The  sugar  is  usually 
milk-sugar  from  the  breasts.  True  diabetes  is  very  seri- 
ous. The  kidneys  and  liver  are  the  weak  spots  of  the 
patient  during  pregnancy  and  deserve  special  attention. 

The  patient  usually  puts  on  fat.  The  hips  round  out 
and  there  is  a gain  in  weight — usually  one-thirteenth  of 
the  ordinary  weight  in  the  non-pregnant  state;  but  the 
woman  may  get  very  fat.  Part  or  all  of  this  may  disap- 
pear afterward,  especially  if  the  mother  nurses  her  infant. 
It  seems  as  if  nature  lays  up  a stock  of  heat  and  energy 
in  the  form  of  fat  for  the  labor  and  lactation. 

The  skin  often  turns  darker,  especially  in  brunets 
and  in  all  women  there  is  some  pigmentation  of  the  linea 
alba,  the  navel,  and  the  nipples.  The  pigment  is  largely 
reabsorbed  after  delivery.  Occasionally  the  face  is  al- 
most covered  with  a brownish  pigmentation  resembling 
freckles  closely  run  together — the  so-called  “mask  of 
pregnancy.”  This  likewise  disappears  nearly  completely 
after  labor.  The  sebaceous  and  sweat-glands  are  more 
active,  and  the  active  perspiration  makes  the  patient 
more  liable  to  colds.  Lineae  or  striae  gravidarum,  the 
purplish  lines  described  as  occurring  on  the  breasts,  ap- 
pear on  the  abdomen  in  larger  number  and  sometimes  on 
the  thighs  (Fig,  29).  These  striae  are  due  to  the  stretch- 
ing of  the  skin,  and  are  more  common  in  some  women 
than  in  others.  Occasionally  they  are  absent,  though 
the  woman  has  had  several  children. 

The  Mouth. — The  salivary  secretion  is  increased,  some- 
times pathologically,  so  that  there  is  constant  dribbling 
of  saliva.  This  latter  is  called  ptyalism  and  is  similar  to 
the  excessive  vomiting  of  pregnancy,  with  which  it  is  fre- 
quently associated.  The  physician  is  to  be  informed  of  it. 

The  teeth  easily  decay.  There  is  an  old  saying, 
“every  child  a tooth.”  This  decay  is  due  to  the  change 


MATERNAL  CHANGES  IN  PREGNANCY 


53 


in  the  secretions  in  the  mouth,  not,  probably,  to  the 
child  using  up  the  lime  salts  of  the  body.  (For  the 
Treatment,  see  page  248.) 

The  patient  is  sometimes  sick  at  the  stomach  in  the 
morning — the  so-called  “morning  sickness  ” — and  this 


Fig.  29. — Striae  gravidarum. 


is  one  of  the  diagnostic  points  of  pregnancy.  Taste  is 
perverted;  the  patient  craves  all  sorts  of  unusual  things, 
which  are  sometimes  indigestible.  One  may  humor 
these  peculiar  cravings  if  the  article  is  not  harmful. 
Sometimes  these  cravings  evidence  insanity,  as  in  the 
case  of  a woman  who  craved  a bite  of  her  husband’s  arm 


54  PREGNANCY,  LABOR , AND  THE  PUERPERIUM 


and  actually  took  it.  The  wife  of  Camerius,  a famous 
botanist  of  the  sixteenth  century,  enjoyed  herself  during 
pregnancy  by  breaking  eggs  on  her  husband’s  face. 

Owing  to  the  cramped  position  of  the  bowels,  con- 
stipation is  a common  symptom,  which  grows  worse  as 
pregnancy  advances  and  always  requires  treatment. 
(See  page  84.) 

The  Nervous  System. — Women  are  more  sensitive  and 
irritable  during  pregnancy;  sometimes  there  is  a change 
in  character,  for  example,  pyromania,  kleptomania  de- 
veloping. Sweet-tempered  women  may  be  soured,  and 
vice  versa.  Sometimes  they  are  morally  uncertain, 
showing  impaired  judgment  of  right  and  wrong.  Neural- 
gias, especially  of  the  face  and  teeth,  are  common.  One 
must  exercise  care  in  the  extraction  of  teeth  to  relieve  the 
pain,  as  healthy  teeth  may  be  needlessly  sacrificed. 
Sometimes  there  is  prickling  of  the  skin  in  the  extremi- 
ties, or  a general  itching  which  may  resist  treatment. 
It  is  thus  seen  how  gestation  tests  the  integrity  of  every 
structure  in  the  body. 

LABOR 

Pregnancy  begins  with  conception  and  ends  with  the 
expulsion  of  the  fetus  and  secundines  from  the  parturient 
canal.  It  lasts  normally  ten  lunar  months,  forty  weeks, 
two  hundred  and  eighty  days,  though  the  time  may  be 
two  weeks  more  or  less.  In  some  women  the  fetus  de- 
velops quicker  than  in  others,  a child  at  eight  months 
equaling  the  children  of  others  at  nine  months.  The 
process  by  which  the  fetus  and  secundines  are  expelled 
is  called  labor.  If  labor  should  come  on  two  weeks 
before  its  expected  time,  or  at  any  previous  period  in  the 
last  three  lunar  months  of  pregnancy,  we  call  it  prema- 
ture. The  child  is  viable  at  the  end  of  seven  lunar 
months  or  twenty-eight  weeks.  It  is  not  strong  and  may 


LABOR 


55 


die  shortly  after  birth.  Any  interruption  of  pregnancy 
after  viability  of  the  child,  but  before  two  weeks  before 
the  expected  time  of  labor,  we  call  premature  labor. 
Should  a woman  go  into  labor  and  expel  the  product  of 
conception  before  the  child  is  viable — that  is,  capable  of 
carrying  on  extra-uterine  existence — we  speak  of  abor- 
tion. Abortion , therefore,  is  the  interruption  of  preg- 
nancy before  the  end  of  the  twenty-eighth  week.  The 
women  call  all  premature  interruptions  of  gestation 
“miscarriage”;  the  term  abortion  to  them  means  a 
criminal  process,  and,  therefore,  if  one  employs  it,  one 
should  not  fail  to  explain  its  scientific  significance. 

When  labor  is  over  the  uterus  immediately  begins 
to  return  to  its  original  size.  This  is  called  involution. 
At  the  same  time  a powerful  stimulus  is  given  to  the 
breasts — lactation  is  established. 

Labor  may,  therefore,  be  defined  as  that  function  by 
which  the  fetus  and  secundines  are  expelled  through  the 
natural  passages,  the  retrogressive  changes  in  the  genitals 
started,  and  the  secretion  of  milk  inaugurated.  There 
are  three  points  to  this  definition.  The  cause  of  labor — 
what  influences  the  uterus  which  has  carried  its  burden  so 
long,  suddenly  and  violently  to  expel  it — is  not  known. 

Labor  does  not  usually  come  on  without  warning: 
there  are  premonitory  symptoms.  Usually  the  woman 
feels  heavy  and  unwieldy  in  the  last  weeks,  her  gait  is 
laborious,  the  bowels  may  become  loose,  urination  more 
frequent,  a free  discharge  of  mucus  from  the  genitals 
may  be  noted,  and  she  has  fleeting  pains  in  the  abdomen 
and  elsewhere.  There  are  three  distinct  signs  that  the 
time  is  nearing — lightening,  false  pains,  and  the  show. 

i.  Lightening.  In  the  last  two  weeks,  especially  in 
primiparae,  the  child’s  head  sinks  into  the  pelvis  and  its 
body  falls  a little  forward.  The  uterus  sinks  down  and 
forward  with  the  child.  The  waist-line  lowers,  the  stom- 


56  PREGNANCY, , LABOR , AND  THE  PUERPER/UM 


ach  region  is  flatter,  the  navel  more  prominent.  The 
patient  breathes  easier,  but  walks  less  well.  The  head, 
entering  the  small  pelvis,  interferes  with  the  bladder 
and  frequent  urination  results.  The  rectum  suffers  also, 
and  the  bowels  are  constipated.  This  phenomenon  is 
called  “ lightening”  or  “ dropping”  by  the  people,  and  is 
sometimes  attended  with  slight  pains  similar  to  labor- 
pains  (Figs.  30  and  31).  It  is  a good  sign,  indicating 
that  there  is  no  mechanical  disproportion  between  the 


Fig.  30-  Fig.  31. 

Figs.  30  and  31. — Silhouettes  of  a woman  before  and  after  lightening  occurs. 


head  and  the  pelvis — that  is,  that  the  head  is  not  too 
large  for  the  pelvis. 

2.  False  Pains. — Sometimes,  especially  in  multi- 
part, for  a few  days  to  three  weeks  before  labor  the 
patient  is  annoyed  by  pains  in  the  abdomen.  These 
often  occur  at  night  and  pass  off  by  morning;  they  are 
sometimes  due  to  gas  in  the  bowels,  when  they  are  re- 
lieved by  castor  oil  and  an  enema.  They  are  sometimes 
due  to  painful  uterine  contractions,  which  subside  after 
a hot  bath,  a warm  drink,  and  an  enema.  In  rare 


LABOR 


5 7 


cases  an  anodyne  is  needed.  These  false  pains  are 
annoying,  as  they  may  closely  resemble  actual  labor  and 
summon  the  physician  and  nurse  unnecessarily. 

3.  The  Show.  -A  few  hours  to  twenty-four  hours 
before  labor  really  begins  there  is  a discharge  from  the 
vagina  of  thick  mucus,  more  or  less  stained  with  blood. 
This  is  called  the  show,  and  is  the  plug  of  mucus  which 
fills  the  cervical  canal  during  pregnancy.  Sometimes 
the  show  is  absent  or  appears  after  labor  has  been  in  prog- 
ress for  a while.  If  there  is  any  pure  blood  with  the 
show  it  is  unusual,  and  the  physician  should  be  notified. 

The  bag  of  waters  may  rupture  as  the  first  indication 
of  approaching  labor.  This  is  undesirable,  because  the 
most  favorable  means  of  dilating  the  mouth  of  the  uterus 
is  thus  lost.  The  patient  then  has  what  is  known  as  a 
“dry  labor,”  which  is  often  slow,  tedious,  and  painful. 

Labor  is  divided  into  three  stages:  The  first  stage 
extends  from  the  time  of  beginning  of  the  labor-pains  to 
the  complete  dilatation  of  the  os  uteri.  It  is  called  the 
period  of  dilatation.  The  bag  of  waters  usually  ruptures 
at  the  end  of  the  first  stage. 

The  second  stage  comprises  the  period  from  the  time 
of  complete  dilatation  of  the  cervix  to  the  end  of  the 
expulsion  of  the  child.  It  is  called  the  period  of  ex- 
pulsion. 

The  third  stage  extends  from  the  time  of  expulsion  of 
the  child  until  the  after-birth  has  been  expelled,  and  the 
uterus  has  contracted  down  on  itself.  It  is  called  the 
placental  stage. 

If  one  observes  a labor  critically,  the  process  makes  the 
impression  of  being  a mechanical  operation,  consisting  of 
the  action  of  some  expellent  power  on  the  fetus  and  pla- 
centa, forcing  them  through  the  maternal  parts  into  the 
external  world.  Thus  the  factors  of  this  mechanical 
operation  are:  the  powers  (the  forces  that  prepare  the 


58  PREGNANCY,  LA  BOP,  AND  THE  PUEKPERIUM 

way  and  drive  the  child,  etc.,  along),  the  passages  (the 
cervix,  vagina,  vulva),  and  the  passengers  (the  child, 
placenta,  etc.).  The  passengers — the  child  and  placenta 
— have  been  described  on  pages  41-46.  The  passages,  too 
— the  pelvis,  vagina,  and  vulva — have  been  described  on 
pages  21-28. 

The  powers  remain  to  be  studied.  They  are  mainly 
two — the  uterus,  a hollow,  strongly  muscular  organ,  and 
the  abdominal  muscles.  The  abdominal  muscles  act 
during  the  second  stage  of  labor  as  they  do  in  procuring 
an  evacuation  of  the  bowels,  that  is,  by  bearing  down 
or  straining.  The  force  thus  exhibited  is  sometimes 
enormous,  and  the  patient  may  injure  herself  if  it  is  not 
properly  restrained.  The  uterus  acts  by  rhythmic  con- 
tractions called  “pains.” 

All  three  stages  of  labor  are  characterized  by  pains. 
These  pains  represent  uterine  contractions,  and  the  two 
terms  are  used  synonymously.  Uterine  contraction  in 
all  languages  is  expressed  by  the  same  word  that  means 
pain — for  example,  in  German,  Wehen;  Italian,  dolor es; 
French,  douleurs. 

The  Tabor-pains. — The  uterus  contracts  at  irregu- 
lar intervals  throughout  pregnancy,  but  there  is  no  pain. 
Late  in  pregnancy  there  may  be  some  pain,  but  usually 
when  the  uterine  contractions  become  painful  labor  has 
begun,  and  this  is  our  most  reliable  outward  sign  of  the 
advent  of  labor.  When  the  “pains”  begin  and  become 
rhythmic  we  consider  the  woman  in  labor.  If  one 
observes  the  abdomen  when  a pain  comes  on — that  is, 
when  the  uterus  contracts — one  feels  the  organ  harden 
all  over;  it  rises  toward  the  ribs  and  stands  out  more 
prominently.  With  a strong  pain  the  uterus  becomes 
almost  boardlike  in  hardness.  As  the  pain  goes  away 
the  uterus  softens  and  loses  its  sharp  contour,  and  the 
abdomen  flattens. 


LABOR 


59 


In  the  beginning  of  labor  the  pains  are  far  apart,  but 
as  it  progresses  the  intervals  decrease  gradually,  being 
one  hour,  thirty  minutes,  fifteen,  ten,  six,  five  minutes, 
until,  toward  the  very  end,  one  pain  follows  almost  im- 
mediately after  the  other.  The  nurse  may  judge  the 
rapidity  of  the  labor  by  the  frequency  and  strength  of 
the  pains.  The  parturient  feels  the  pains  at  first  in  her 
back  (the  “kidney  pains”  of  the  French),  and  they  are 
not  so  painful,  but  as  labor  goes  on  they  are  felt  more  to 
the  front  and  are  severer.  When  the  woman  is  well  on 
in  the  first  stage  she  describes  the  pains  as  grinding, 
later  as  cutting,  and  in  the  second  stage  they  are  “bear- 
ing-down” pains.  The  pains  or  the  uterine  contractions, 
aided  by  the  action  of  the  abdominal  muscles,  are  the 
most  important  powers  of  labor. 

The  Bag  of  Waters. — The  first  effect  of  the  uterine 
contraction  is  the  formation  of  the  “bag  of  waters.” 
That  part  of  the  fetal  sac,  or  the  membranes  inclosing 
the  child,  which  covers  the  internal  os  is  forced  into  the 
os  from  within  outward.  The  cervix  being  the  point  of 
least  resistance  in  the  uterus,  when  the  uterus  contracts 
it  forces  the  liquor  amnii  in  this  direction.  The  os  being 
covered  by  the  membranes,  these  latter  are  forced  out  in 
the  form  of  a pouch.  This  pouch  is  called  the  bag  of 
waters,  and  it  has  important  functions.  First,  it  dilates 
the  cervix  and  the  vagina  gently,  evenly,  and  safely; 
second,  it  protects  the  baby  from  injurious  pressure  on 
any  one  part,  because  when  the  uterus  contracts  the 
force  exerted  presses  equally  in  all  directions,  answering 
to  the  law  of  pressure  on  fluids;  third,  it  protects  the 
cord  from  prolapsing;  and  fourth,  if  there  is  infection  in 
the  vagina,  it  prevents  this  from  getting  into  the  uterus 
or  into  the  baby’s  eyes.  (See  Plate  II.)  Some  authors 
call  the  whole  fetal  sac  the  “bag  of  waters.” 

When  the  cervix  is  completely  opened,  so  that  the 


60  PREGNANCY,  LAB  OP,  AND  THE  PUERPERIUM 


uterine  cavity  forms  a continuous  canal  with  the  vagina 
(the  parturient  canal),  the  membranes  usually  rupture, 
but  they  may  not  until  later,  or  may  rupture  before  the 
pains  begin.  This  last  then  leads  to  a so-called  “dry 
labor.”  If  the  baby  is  born  with  the  membranes  cover- 
ing its  head,  it  is  said  to  be  born  with  a “caul,”  and  it  is 
considered  a lucky  omen. 

When  the  uterus  contracts,  everything  in  it  is  forced 
out  in  the  direction  of  the  cervix.  The  child  is  forced 
against  the  os,  and,  when  this  is  large  enough,  the  head 
passes  through  it  into  the  vagina.  The  pains,  aided  now 


Fig.  32. — Diagram  showing  the  advancement  of  the  head  through  the  pelvis 
(Leishman) . 

by  the  voluntary  bearing-down  efforts  of  the  woman, 
drive  the  head  along  the  vagina.  The  perineum  now 
begins  to  darken  in  color  and  to  bulge  outward,  and  the 
anus  opens,  so  that  the  anterior  rectal  wall  lies  exposed. 
The  pains  are  about  two  minutes  apart  and  very  strong. 
The  vulva  begins  to  open,  and  soon  the  wrinkled  scalp 
is  visible  (Fig.  32).  Under  the  actions  of  the  pains  and 
strong  pressing  efforts  of  the  mother  the  vulva  is  dilated 
so  as  to  allow  the  passage  of  the  child.  Sometimes  the 
parts  will  not  dilate,  but  tear,  or  the  doctor  has  to  incise 
the  vulva  to  permit  the  escape  of  the  child.  This 


A 


PLATE  II 


0 Placenta 


Contraction 

Ring 


* ectum 


Bladder 


wRectum 


Urethra 


K Bag  of 
Waters 


Braune’s  frozen  section  of  a woman  who  died  at  the  end  of  the  first  stage 
of  labor.  Shows  the  bag  of  waters  at  the  vulvar  outlet. 


PURRPERWM 


6l 


operation  is  called  episiotomy.  After  the  head  is  deliv- 
ered the  face  turns  to  one  side  and  there  is  a short  pause, 
after  which  the  shoulders  come,  followed  at  once  by  the 
trunk.  The  child  gives  a sneeze  or  a gasp,  and  soon 
cries  lustily.  Now  come  blood,  liquor  amnii,  sometimes 
meconium,  and  the  ends  of  the  membranes. 

The  pains  cease  and  the  patient  feels  much  relieved. 
The  second  stage  is  ended;  the  third  stage  begins.  After 
a short  rest,  during  which  the  uterus  may  be  felt  as  a 
roundish  body  the  size  of  a cocoanut,  lying  under  the 
navel,  the  pains  recommence — the  after-pains.  These 
bring  about  the  separation  and  expulsion  of  the  placenta. 
Sometimes  there  is  a little  hemorrhage  with  each  pain. 
The  pains  recur  every  three  or  five  minutes.  Soon  the 
cord  slides  down  a little  from  the  vulva  and  the  patient 
bears  down,  or  the  doctor  presses  on  the  uterus  and  the 
after-birth  appears.  The  nurse  receives  it  in  a sterile 
basin,  or  the  physician  takes  it,  gently  pulling  on  the 
membranes,  which  strip  off  slowly  from  the  uterus. 
There  is  always  more  or  less  blood  when  the  placenta 
comes,  and  a little  more  follows  it.  The  uterus  now 
contracts  down  into  a hard  ball  behind  the  pubis,  and 
the  third  stage  of  labor  is  ended.  The  puerperium  is 
now  begun — the  woman  is  a puerpera.  If  she  has 
already  borne  children  the  after-pains  continue  more  or 
less  severely,  and  for  a period  of  one  or  more  days. 

THE  PUERPERIUM 

The  puerperium  is  characterized  by  the  return  of  the 
genital  organs  to  their  previous  condition  and  the  de- 
velopment of  the  breasts  for  the  function  of  lactation, 
that  is,  to  carry  still  further  the  function  of  reproduction. 
Retrogressive  changes  occur  in  the  genitalia;  progress- 
ive changes,  in  the  breasts. 

The  uterus,  which  after  labor  is  the  size  of  a small 


62  PREGNANCY,  LABOR , AND  THE  PUERPERIUM 

cocoanut  and  weighs  about  2 pounds,  by  a process  of 
fatty  degeneration  and  absorption  quickly  diminishes 
in  volume.  The  nurse  can  observe  this  by  feeling  daily 
the  fundus  of  the  uterus  and  measuring  from  its  top  to 
the  pubis.  On  the  first  day  the  uterus  is  high — even 


Fig-  33- — Height  of  uterus  postpartum,  the  bladder  empty:  L,  After  labor; 
1,  first  day;  2,  second  day,  etc. 


above  the  navel;  on  the  third  day  it  is  eight  fingers’ 
breadth  above  the  pubis;  on  the  fifth  day,  six  fingers’. 
On  the  twelfth  day  it  is  at  the  pubis,  and  after  this 
normally  cannot  be  felt  through  the  abdomen  (Fig. 
33).  If  the  bladder  or  rectum  is  full  the  uterus  is 
pushed  up  higher  (Fig.  34). 


PUEKPERIUM 


63 


The  I/Ochia.-  -The  lining  membrane  of  the  uterus, 
the  endometrium,  is  cast  off  and  renewed  during  the 
puerperium.  This  is  attended  by  a flow  of  fluid  from 
the  genitals  called  the  lochia.  The  lochia  varies  in  ap- 
pearance and  consistence  from  day  to  day,  and  varies  in 
different  women,  also  with  the  kind  of  labor  the  patient 
has  had. 

On  the  first  day  the  lochia  is  bloody — lochia  cruenta. 
Sometimes  there  are  clots.  If  these  are  large,  the  case 


is  abnormal.  Note  the  expulsion  of  the  clots,  mem- 
brane, etc.,  on  the  history-sheet,  and  save  anything 
abnormal  for  the  doctor’s  inspection,  either  fresh, 
wrapped  in  a wet  cloth,  or  in  50  per  cent,  alcohol.  On 
the  second  and  third  days  the  lochia  is  still  bloody, 
but  there  is  quite  an  admixture  of  serum.  It  is 
called  lochia  sanguinolenta , or  is  said  to  be  serosan- 
guineous.  For  a few  days  now  the  lochia  is  creamy 
and  reddish.  After  the  sixth  day  there  is  quite  an 
admixture  of  fatty  detritus  and  pus-corpuscles,  which 


Fig.  34. — Uterus  pushed  up  by  full  bladder. 


64  PREGNANCY,  LABOR , AND  THE  PUERPERIUM 

make  the  discharge  purulent — lochia  purulenta.  Later 
in  the  puerperium  there  is  only  a watery  clear  dis- 
charge— lochia  serosa.  Sometimes  the  bloody  lochia 
persists  for  several  weeks.  Microscopically,  about  the 
third  day,  the  lochia  contains  red  and  white  blood-cor- 
puscles, epithelium  from  the  genital  tract,  bits  of 
necrotic  or  dead  endometrium,  or  decidua , and  millions 
of  microbes.  These  germs  are  not  virulent  unless  the 
puerpera  is  septic  or  unless  they  are  introduced  into 
conditions  favorable  to  their  growth.  Thus  the  lochia 
of  one  puerpera  might,  if  introduced  into  the  vagina, 
infect  another  puerpera.  Nurses  have  infected  their 
fingers  by  the  lochia  of  normal  puerperae,  and  that 
infection  may  be  carried  from  here  to  the  breasts  is 
generally  admitted. 

The  amount  of  lochial  discharge  varies  from  day  to 
day  and  in  different  women.  It  varies  also  according 
to  the  nature  of  the  labor  and  the  conduct  of  the  third 
stage.  Women  who  menstruate  freely  have  profuse 
lochia;  operative  cases  have  much  for  the  first  few  days; 
when  the  uterus  has  been  thoroughly  emptied  at  a labor 
the  discharge  is  scanty.  The  lochia  may  be  pent  up  in 
the  uterus  and  give  rise  to  fever. 

The  odor  of  the  lochia  changes  during  the  continuance 
of  the  flow,  being  at  first  bloodlike;  later  it  resembles 
that  characteristic  of  the  patient.  A foul  or  putrid 
odor  is  always  indicative  of  infection,  though  the  infec- 
tion may  not  be  serious.  (See  chapter  on  Puerperal 
Infection.) 

The  vulva  and  the  vagina  after  labor  are  dark, 
bruised,  and  more  or  less  torn  and  abraded.  There 
is,  usually  in  primiparae,  more  or  less  swelling.  This 
edema  is  quickly  absorbed,  also  the  ecchymoses.  All 
these  processes  are  grouped  together  and  called  “in- 
volution.” Involution,  then,  may  be  defined  as  that 


PUERPERIUM 


65 


group  of  processes  occurring  when  the  uterus  and  other 
genital  organs  return  to  their  usual  conditions.  The 
health  of  the  woman  depends  on  the  involution  proceed- 
ing undisturbed. 

The  breasts  take  on  their  greatest  activity  during 
the  puerperium.  Whereas  the  processes  going  on  in 
the  pelvic  genitalia  are  retrogressive,  bringing  those 
structures  back  to  their  previous  condition,  the  changes 
occurring  in  the  breasts  are  progressive — designed  to 
further  carry  on  the  function  of  reproduction. 

On  the  first  day  the  infant  obtains  the  secretion 
known  as  colostrum.  This  is  rather  indigestible  and 
produces  catharsis.  Even  of  the  colostrum  there  is 
very  little  the  first  day,  so  that  the  infant  practically 
starves.  On  the  second  day  there  is  more  secretion  in 
the  breasts,  and  it  is  quite  yellow  from  the  admixture 
of  butter-fat.  On  the  second  day  in  multiparae,  and 
on  the  third  in  primiparae,  there  is  usually  a rush  of 
blood  and  lymph  into  the  breasts.  They  are  swollen, 
enlarged,  turgid  with  blood,  painful  and  tender,  and 
feel  hot.  The  patient,  when  the  engorgement  is  marked, 
may  be  in  much  distress.  The  breasts  are  sometimes 
so  large  and  hard  that  the  nipple  is  flattened  and  the  baby 
cannot  grasp  it  for  nursing.  Since  the  breasts  are  thus 
not  emptied,  the  engorgement  is  not  relieved.  This 
condition  is  popularly  thought  to  be  a rush  of  milk  to 
the  breasts,  but  it  is  nothing  but  an  acute  engorgement 
of  the  organs.  No  milk  is  formed,  but  it  is  ready  to  be 
formed,  and  needs  only  the  stimulation  of  nursing. 
Should  the  child  not  nurse  the  engorgement  would 
gradually  subside.  If  it  nurses  the  milk  is  made,  and 
mostly  during  the  nursing  itself.  In  multiparae,  and 
after  lactation  is  established,  the  breasts  having  formed 
the  habit  of  making  milk  at  certain  periods,  do  so,  and 
thus  there  comes  to  be  a little  milk  in  the  breasts;  but 
5 


66  PR  E GNANC y,  LABOR , AND  THE  PUERPERIUM 


this  is  not  the  rule,  nor  is  the  quantity  large,  and  herein 
lies  the  fallacy  of  pumping  the  breasts  continually  to 
relieve  them.  It  is  not  overfilling  with  milk  that  is 
giving  the  trouble,  but  lymphatic  and  venous  engorge- 
ment, and  measures  for  relief  should  be  directed  toward 
these.  Under  appropriate  treatment  the  engorgement 
subsides  spontaneously  in  a day  or  so,  and  the  func- 
tion of  lactation  is  gradually  established.  (For  Treat- 
ment, see  p.  308.) 

The  engorgement  of  the  breasts  is  not  accompanied 
by  fever.  There  is  no  such  thing  as  “milk-fever.” 
When  there  is  fever  about  the  time  that  lactation  is 
being  established,  its  cause  must  be  sought  elsewhere, 
and  some  form  of  sepsis  will  usually  be  found. 

GENERAL  CHANGES  IN  THE  PUERPERIUM 

The  general  condition  of  the  woman  during  the 
lying-in  period  is  different  in  some  respects  from  that 
of  other  women.  The  temperature  is  sometimes  a little 
higher  than  normal.  It  may  rise  to  99. 50  F.  and  not 
be  pathologic,  though  the  writer  is  accustomed  to 
regard  every  rise  above  99°  F.  with  suspicion.  Any- 
thing above  ioo°  F.  is  certainly  indicative  of  disease. 

The  pulse  ought  to  be  below  88.  If  higher,  there  is 
usually  something  wrong,  as  hemorrhage,  infection, 
heart  disease,  etc.  Sometimes  a woman  has  naturally 
a rapid  heart. 

Kidneys.  -The  patient  passes  much  urine  during 
this  time — polyuria — therefore  the  nurse  should  see 
that  the  bladder  is  not  overfilled,  because  it  may  cause 
hemorrhage  from  the  uterus  and  cystitis.  When  the 
bladder  is  overfilled  it  makes  a soft  tumor  above  the 
pubis  (see  Fig.  34),  pushing  the  uterus  up  and  to  one 
side.  Retention  of  the  urine  after  labor  is  common. 
If  the  bladder  overflows,  this  condition  is  called  ischuria 


GENERAL  CHANGES  IN  THE  PUERPERIUM  6y 


paradoxa.  The  inability  to  urinate  is  due  to  several 
causes:  first,  the  horizontal  position  in  bed,  some 

patients  finding  it  impossible  to  urinate  lying  down; 
second,  to  the  bruising  and  swelling  of  the  urethra 
caused  by  the  labor;  third,  the  abdominal  walls  are 
weak  from  overstretching  during  pregnancy.  In  hys- 
teric women  and  after  some  operations  the  amount  of 
urine  may  reach  from  3 to  5 quarts. 

Bowels.  Constipation  is  the  rule  because  the 
patient  is  quiet  on  her  back,  and  because  the  abdominal 
muscles  are  stretched  and  the  intestines  inactive  from 
being  in  a cramped  position  so  long.  Not  seldom 
there  is  tympanites.  In  pathologic  cases  this  may 
require  special  treatment.  Rarely  it  is  fatal. 

The  skin  is  active,  the  patient  sweats  freely,  and 
therefore  is  more  subject  to  chilling — an  important 
hint.  There  is,  too,  a peculiar  and  somewhat  charac- 
teristic odor  about  the  patient.  This  may  be  altered 
by  disease,  as  uremia  or  sepsis. 

The  mental  condition  is  altered,  the  patient  being 
more  susceptible  to  nervous  influences;  therefore  the 
general  desire  to  keep  parturient  women  free  from  all 
worry  and  excitement.  In  Roman  times  a criminal 
was  safe  if  he  took  refuge  in  the  house  of  a puerpera, 
and  even  the  tax-gatherer  was  debarred.  It  is  claimed 
by  some  that  a puerperal  woman  is  so  sensitive  to 
nervous  shock  that  such  may  cause  an  acute  rise  of 
temperature.  The  writer  has  seen  a few  instances 
where  the  fever  could  not  well  be  explained  on  any 
other  grounds,  but  such  a diagnosis  is  hard  to  prove. 


CHAPTER  IV 


THE  NEWBORN  INFANT 

THE  BABY  IN  THE  FIRST  WEEKS 

As  soon  as  the  child  is  born  close  observation  will 
show  tiny  respiratory  movements  of  the  chest;  then 
comes  a gasp  or  a sneeze  which  clears  the  air-passages; 
then  a short  cry;  finally,  the  lusty  crying.  These  few 
moments  are  crucial.  The  change  from  the  uterine 
circulation  of  the  blood  to  the  extra-uterine  is  now 
taking  place.  The  lungs  are  expanding;  the  blood- 
currents  are  taking  the  directions  they  are  permanently 
to  follow.  Should  the  lungs  not  expand  fully,  sufficient 
air  cannot  enter  and  the  child  remains  blue,  and  if  the 
condition  is  marked,  it  will  die  after  a period  of  from 
two  to  forty-eight  hours.  During  this  time  each 
breath  drawn  by  the  infant  is  marked  by  an  expiratory 
grunt  or  whining  cry.  It  is  pitiful  to  hear,  and  soon 
the  infant  becomes  unconscious  and  finally  comatose. 
This  condition  is  called  atelectasis  pulmonum , and  is 
much  more  common  in  premature  infants.  The  res- 
piration of  even  a healthy  infant  is  irregular,  and  for  a 
few  hours  the  child  may  be  a little  bluish  around  the 
mouth  and  nose,  but  this  disappears  fully,  being  re- 
placed by  the  healthy  pink  or  red. 

The  cry  of  a newborn  infant  is  lusty  at  first, 
then  the  infant  quiets  and  cries  only  when  hungry,  un- 
comfortable, disturbed,  or  sick.  A whining  cry  is  sug- 
gestive of  atelectasis,  prematurity,  and  illness;  a sharp, 
68 


THE  BABY  IN  THE  FIRST  WEEKS  69 

high-pitched  cry,  of  cerebral  trouble;  a sharp,  loud  cry 
with  kicking  of  the  legs,  of  hunger  or  colic ; a fretful  cry, 
with  borborygmus  (rumbling  in  the  bowels)  and  green- 
ish stools,  of  indigestion. 

Sleep. — The  newborn  infant  sleeps  nearly  all  the 
time  when  it  is  not  disturbed.  After  a week,  but  some- 
times sooner,  it  usually  begins  to  show  signs  of  intelli- 
gence. It  moves  in  its  sleep,  and  occasionally  muscu- 
lar jerks  may  be  seen,  due  to  a jar  or  sudden  light.  If 
the  child  does  not  sleep,  something  is  wrong. 

The  temperature  varies  normally  from  98°  to  990  F., 
usually  it  is  98.4°  F.  In  premature  infants  the  tem- 
perature is  970  to  98.6°  F.  or  lower  if  they  are  not 
kept  warm.  The  normal  pulse-rate  is  from  120  to  140 
a minute.  The  respirations  are  38  to  44  a minute. 
The  pulse  is  made  more  rapid  by  the  least  disturbance. 
It  is  difficult  to  count  and  is  felt  best  in  the  temple  and 
while  the  child  sleeps. 

The  skin  is  at  first  bluish  pink,  becoming  in  a few 
hours  pink  or  red.  At  birth  it  is  more  or  less  covered 
with  a white,  thick,  cheesy  material,  the  vernix  caseosa, 
which  is  composed  of  epithelial  cells,  lanugo,  and  seba- 
ceous secretion  accumulated  on  the  skin  during  intra- 
uterine life.  During  the  first  days  the  skin  dries  and 
may  crack  in  the  folds;  it  may  desquamate  in  more  or 
less  large  flakes.  In  many  babies — over  half — there 
is  a yellowish  color  to  the  skin  after  the  third  day, 
the  so-called  icterus  neonatorum , or  jaundice  of  the 
newborn.  It  has  several  causes,  but  the  exact  nature  is 
is  not  known.  If  the  jaundice  is  slight  the  general 
health  of  the  baby  is  not  affected,  and  the  skin  clears  in  a 
few  days;  but  if  the  child  is  deeply  jaundiced  the  con- 
dition may  indicate  a serious  disease.  These  cases  are 
slow  to  lose  the  yellow  color.  The  children  remain  for 
a long  time  weak,  small,  and  puny. 


7° 


THE  NEWBORN  INFANT 


The  Navel.  The  umbilical  cord  is  tied  and  cut  off 
J to  i inch  from  the  skin  margin.  The  stump  of  the 
cord  in  a few  days  shrivels  up  to  a thin,  tough  strand. 
At  the  edge  of  the  skin,  where  the  cord  has  been  in- 
serted, a line  of  granulation  forms  which  separates  the 
stump  of  the  cord.  The  cord  usually  drops  off  from 
the  fifth  to  the  fifteenth  day;  it  may  be  sooner  or  later 
than  this.  The  process  is  one  of  aseptic  necrosis,  the 
wound  healing  by  granulation  and  cicatrization.  Care- 
ful asepsis  must  be  observed  in  the  treatment  of  the 
stump,  so  that  sepsis  does  not  interfere  with  the  process. 

The  Baby’s  Bowels. — For  the  first  three  days 
the  infant  passes  a thick,  dark-green,  tarry  material, 
called  meconium.  This  has  been  accumulating  in  the 
bowel  since  the  fetus  was  very  small,  as  it  is  found  in 
the  intestine  of  fetuses  expelled  in  the  early  months  of 
pregnancy.  When  the  child  is  from  three  to  five  days 
old  the  movements  are  brownish  in  color,  and  then 
gradually  there  is  an  admixture  of  yellow  from  the  food. 
By  the  sixth  day  usually  the  green  has  entirely  disap- 
peared and  the  movements  are  pure  yellow.  This  is 
the  normal  process.  The  green  may  persist  longer  in 
some  cases.  The  odor  of  a healthy  baby’s  stools  is  not 
bad,  resembling  somewhat  that  of  sour  milk,  and  the 
color  should  be  golden  yellow.  There  should  be  no 
mucus  in  them,  and  the  water-line  outside  the  solid 
part  of  the  bowel  movement  should  not  be  more  than 
| inch  wide.  Greenish,  frothy,  slimy,  foul-smelling, 
acrid  stools  betoken  intestinal  disease.  A continuance 
of  the  brown  color  shows  insufficient  food. 

The  Kidneys. — The  newborn  infant  generally 
passes  urine  in  the  first  few  hours.  This  must  be 
watched  for,  and  if  absent  the  parts  must  be  inspected 
for  evidence  of  obstruction.  Sometimes  the  napkin  is 
stained  with  a reddish,  brick-dust-like  deposit,  the  so- 


THE  BABY  IN  THE  FIRST  WEEKS 


7l 


called  uric  acid.  In  the  kidneys  of  children  dying  in 
the  first  days  this  same  deposit  is  frequently  found.  The 
urine  in  these  cases  is  too  concentrated  and  requires 
dilution,  which  is  accomplished  by  the  free  adminis- 
tration of  liquids,  especially  water. 

The  Weight.  —The  infant  loses  weight  during  the 
first  four  to  eight  days,  and  then  begins  to  regain  it. 
By  the  eleventh  day  it  again  weighs  as  much  as  when 
born.  Children  vary  much  in  this  regard,  depending 
on  their  constitution  and  on  the  food  they  get.  If 
breast  fed,  and  the  supply  is  abundant,  the  initial  loss 
may  be  small,  and  the  birth-weight  may  be  regained 
before  the  fifth  day  (Fig.  35).  Under  contrary  condi- 
tions the  child  may  weigh  less  in  three  weeks  than  it 
did  when  born.  This  is  especially  true  of  premature 
infants,  as  they  lose  relatively  more — sometimes  a 
quarter — of  their  whole  weight.  They  regain  it  slowly, 
often  remaining  stationary  for  weeks  before  the  little 
body  begins  to  grow. 

Girls  sometimes  have  a little  whitish  discharge  from 
the  vagina,  and  rarely  they  menstruate.  This  lasts  one 
to  five  days  and  is  not  of  serious  moment.  Occasionally 
it  is  too  profuse,  when  a drop  of  extract  of  ergot,  three 
times  daily,  may  be  needed. 


72 


THE  NEWBORN  INFANT 


Fig.  35. — Weight-chart  of  a normal  infant. 


CHAPTER  V 


THE  HYGIENE  OF  PREGNANCY 

Under  this  caption  those  duties  will  be  treated  which 
fall  to  the  lot  of  the  nurse  during  pregnancy.  She  is 
often  consulted  about  various  incidents  of  the  gravid 
state,  first  of  which  is  the  diagnosis  of  the  condition 
itself. 

Diagnosis  of  Pregnancy.— This  is  not  always 
easy,  even  late  in  pregnancy,  and  in  the  early  months 
may  not  be  made  positively  even  by  an  expert  accou- 
cheur. The  nurse  has  the  following  points  on  which  to 
base  a diagnosis  of  pregnancy: 

1.  The  Cessation  of  the  Menses  in  a Healthy  Woman. — 
If  a woman  in  good  health  ceases  to  menstruate  during 
the  period  of  reproductive  life,  the  probability  is  very 
strong  that  pregnancy  exists. 

2.  The  Morning  Sickness. — If  a woman  apparently 
healthy  is  affected  with  morning  nausea  and  vomiting, 
there  is  a presumption  of  pregnancy,  but  no  more  than 
a presumption.  Together  with  the  absence  of  the 
menses,  the  symptom  has  more  value. 

3.  Enlargement  of  the  Breasts  and  the  Areolar  Signs. — 
These  evidences  are  very  strong,  but  not  certain,  be- 
cause nervous  women  may  show  them  at  their  men- 
strual periods.  Shooting  pains  in  the  breasts,  promi- 
nence of  the  nipples,  puffiness  of  the  areola,  pigmenta- 
tion, and  colostrum  may  be  noticed. 


73 


74 


THE  HYGIENE  OF  PREGNANCY 


4.  Quickening  or  u Feeling  Life” — Since  this  is  a sub- 
jective sign — that  is,  felt  by  the  woman — it  has  no 
positive  value.  Even  matrons  have  imagined  feeling  a 
child  in  the  abdomen  when  none  was  there.  A mother 
of  nine  children  prepared  a complete  outfit  for  the  tenth, 
which  she  imagined  she  felt.  One  patient  of  the  author 
felt  labor-pains  when  she  was  not  even  pregnant. 

5.  Palpation  of  the  Fetus , of  Fetal  Movements , and 
Hearing  the  Fetal  Heart-tones. — These  are  the  only  cer- 
tain signs  of  pregnancy,  but  may  only  seldom  be  elicited 
before  the  fourth  month. 

The  physician  has  other  means  of  diagnosis,  includ- 
ing the  blood-serum  test  just  discovered. 

Diagnosis  of  Time  of  Confinement.  This  can 
never  be  exactly  determined.  An  error  of  two  weeks 
either  way  is  always  possible,  because  we  do  not  know 
when  the  gestation  begins  or  when  it  ends.  The  time  of 
conception  is  not  known,  labor  is  more  or  less  accidental, 
being  sometimes  brought  on  by  external  causes,  and  the 
length  of  pregnancy  varies  in  different  women,  and  in 
the  same  woman  at  different  times.  Therefore  all  state- 
ments as  to  the  exact  time  that  labor  will  occur  are 
conjectural.  Experience,  however,  has  shown  that  we 
can  arrive  at  an  approximate  date,  which,  for  practice,  is 
quite  satisfactory,  if  not  wholly  so. 

1.  Count  back  three  months  from  the  first  day  of  the 
last  normal  menstruation  and  add  seven  days.  For  ex- 
ample, Mrs.  X.  menstruated  last  beginning  October  10th: 
July  17th  is  set  for  confinement. 

2.  Count  twenty- two  weeks  from  the  day  of  quicken- 
ing for  a primipara,  and  twenty-four  weeks  for  a multi- 
para. 

3.  Count  two  hundred  and  eighty  days  from  the  sup- 
posed date  of  impregnation. 

4.  Count  two  weeks  from  the  time  of  lightening. 


MODE  OF  LIVING  FOR  THE  PREGNANT  WOMAN  75 

5.  The  physician  will  measure  the  fetus  by  means  of 
the  pelvimeter  and  the  cephalometer,  and  by  general 
palpation  of  its  body,  and,  judging  from  its  size  and  con- 
sistence, will  say  that  the  child  is  about  thus  and  thus 
far  along  in  development.  Outside  of  the  error  due  to 
uncertain  human  judgment  there  are  other  fallacies,  be- 
cause some  children  at  eight  months  are  larger  than 
others  at  term  and  even  those  carried  over  time. 

Thus  if  a gravida  has  a small  fetus,  it  is  unsafe  to  say 
that  she  is  far  from  term.  The  author  delivered  a 3- 
pound  baby  from  a woman  who  was  beyond  the  ninth 
month  of  pregnancy,  and  on  the  same  day  another  child, 
in  the  eighth  month  of  pregnancy,  that  weighed  8 
pounds. 

MODE  OF  LIVING  FOR  THE  PREGNANT  WOMAN 

Dress.  -The  dress  of  a pregnant  woman  should  be 
simple  and  warm.  There  should  be  no  heavy  skirts. 
There  must  be  no  circular  constriction  at  any  part  of  the 
body,  which  means  that  round  garters,  corsets,  tight 
skirt-bands,  etc.,  must  not  be  worn.  Closed  drawers 
are  essential.  It  is  best  to  wear  wool  next  to  the  skin — 
heavy  in  winter,  light  in  summer — but  many  women  do 
not  do  so.  All  skirts  should  hang  from  the  shoulders, 
from  a waist  or  by  means  of  suspenders.  The  secret  of 
a proper  abdominal  dress  for  pregnant  women  is  that 
there  should  be  no  pressure  on  the  womb  from  above 
downward,  but  the  uterus  should  rather  be  supported 
from  below.  If  a woman  presses  the  uterus  down  by  the 
corset,  all  the  abdominal  organs  are  displaced:  the 
intestines  upward  against  the  stomach  and  diaphragm; 
the  uterus  is  forced  down  against  the  pubis  and  into  the 
pelvis,  pressing  on  the  bladder  (Fig.  36).  All  the  organs 
in  the  pelvis  are  crowded  down  and  venous  congestion 
results,  with  its  train  of  dangers,  immediate  and  future. 


76 


THE  HYGIENE  OF  PREGNANCY 


The  supports  of  the  uterus  and  abdomen  are  weakened, 
and  later  “high  stomach,”  enteroptosis,  or  prolapse  of 
the  abdominal  viscera,  and  displacement  of  the  uterus 
develop.  Further,  the  growth  of  the  child  is  interfered 
with  and  deformities,  such  as  club-foot,  may  thus  be 
caused. 


Fig.  36. — Corset  pushing  the  uterus,  child,  and  other  organs  down  into  the  pelvis. 

Several  corsets  or  waists  especially  designed  for  preg- 
nant women  are  on  the  market.  Some  of  the  best  are 
those  made  by  the  Patterson  and  the  Kabo  Maternity 
(Figs.  37,  38)  waist  manufacturers. 

In  the  latter  half  of  pregnancy  most  women,  and 
expecially  the  multipart,  enjoy  much  comfort  from  a 
well-fitting  abdominal  supporter  such  as  is  worn  after 
laparotomy.  This  helps  the  abdominal  wall  to  carry 
the  weight  of  the  child.  (See  Fig.  129.) 


MODE  OF  LIVING  FOR  THE  PREGNANT  WOMAN  77 

Should  the  breasts  grow  large  and  distress  the  patient 
by  their  weight,  care  should  be  taken  that  sufficient 


Fig*  37* — The  Kabo  abdominal  sup- 
porter, front  view. 


Fig.  38. — The  Kabo  abdominal  sup- 
porter, side  view. 


support  be  given.  This  is  as  much  needed  to  avoid 
injury  of  the  delicate  organs  as  to  insure  comfort. 


73 


THE  HYGIENE  OF  PREGNANCY 


The  pregnant  woman  should  wear  low-heeled  shoes — 
the  so-called  common-sense  shoe  with  broad  toes.  High- 
heeled  shoes  are  distinctly  injurious,  causing  pain  in  the 
back  and  bearing-down  sensations  in  the  abdomen.  A 
glance  at  the  figure  of  a pregnant  woman  will  show 
how  this  comes  about.  Owing  to  the  development  of 
the  abdominal  tumor,  which  tends  to  pull  the  trunk 
forward,  the  woman  throws  her  shoulders  back  and 
straightens  her  neck.  This  balances  the  figure,  but  it 
makes  a sharp  angle  in  the  small  of  the  back.  It  gives 
the  gravida  a peculiar  pose  and  gait  which  did  not  escape 
the  eye  of  Shakespeare,  who  called  it  the  “pride  of 
pregnancy.”  Now  if,  in  addition,  the  pregnant  woman 
wears  high  heels,  the  trunk  is  pushed  still  further  for- 
ward, and  to  save  herself  from  falling  the  gravida  throws 
her  head  and  shoulders  very  far  back,  making  a sharper 
bend  in  the  lumbar  region.  This  causes  pain  here  and 
overstretches  the  abdominal  wall  in  front.  It  is  sad 
to  contemplate  how  the  beautiful  female  form  is  dis- 
torted at  the  behest  of  fashion,  but  it  is  sadder  to  think 
of  the  physical  misery  and  injury  to  health  these  behests 
cause. 

Preservation  of  the  Figure.  -Naturally  and 
properly,  women  are  desirous  that  the  function  of  child- 
bearing should  not  leave  the  person  in  an  ungainly 
shape,  for  example,  with  protuberant  abdomen.  The 
most  common  complaint  is  that  the  patient  develops 
a “high  stomach”  after  labor. 

It  may  be  remembered  that  the  Roman  women  had 
abortions  performed  so  that  they  need  not  suffer  the 
disfigurement  produced  by  child-bearing.  Certain 
changes  in  the  body  are  the  necessary  results  of  child- 
birth and  beautify  the  figure,  although  some  women  do 
not  look  at  it  in  this  light.  Such  are  the  general  rounding 
of  the  hips,  broadening  of  the  bust,  the  more  mature 


PRESERVATION  OF  THE  FIGURE 


79 


and  matronly  appearance.  It  is  natural  for  some  women 
to  put  on  fat  after  delivery,  and  nothing  done  before, 
during,  or  after  confinement  will  prevent  it.  An  excess- 
ive accumulation  is,  however,  amenable  to  the  usual 
treatment  for  obesity.  Antifat  medicines  should  not  be 
taken  during  pregnancy,  and  never  without  the  physi- 
cian’s order. 

For  the  prevention  of  “high  stomach”  or  extreme 
prominence  of  the  lower  abdomen  much  may  be  done. 
The  condition  is  caused  by  weakness  of  the  abdominal 
muscles,  or  even  by  a separation  of  the  recti  muscles, 
when  the  woman  is  said  to  have  a “rupture.”  As  the 
result  of  either,  the  intestines  fill  with  gas  and  fall  for- 
ward; sometimes  the  kidneys  become  movable,  or  even 
the  liver  prolapses.  The  muscles  give  way  under  the 
stretching  produced  by  the  growing  uterus,  and,  of 
course,  will  give  way  sooner  if  there  are  twins  or  an  un- 
usually large  child,  or  if  the  abdominal  walls  are  weak. 
If  corsets  are  worn  during  pregnancy,  they  add  to  the 
strain  on  the  lower  abdomen  and  thus  favor  muscular 
weakness.  High-heeled  shoes  are  another  factor.  Over- 
straining during  labor  and  inattention  to  the  bowels 
after  labor  are  also  causative.  To  prevent  the  muscular 
insufficiency,  one  must  begin  with  the  girl.  She  should 
develop  herself  as  does  the  boy,  with  active  sports — - 
rowing,  swimming,  climbing,  etc.  When  a young 
woman,  she  should  not  “lace”  and  thus  paralyze  the 
abdomen.  Healthy  exercise  of  the  whole  body  should 
form  part  of  her  daily  routine.  The  abdomen  may  need 
some  support  during  the  last  three  months  of  pregnancy, 
which  may  be  obtained  by  one  of  the  maternity  corsets 
recommended.  A special  abdominal  binder,  as  the 
Patterson,  may  sometimes  be  needed,  and  this  in  multi- 
par  ae  with  already  weakened  walls  or  with  twins,  poly- 
hydramnios, etc.  After  the  birth  of  the  child  the 


8o 


THE  HYGIENE  OF  PREGNANCY 


nurse  should  see  that  the  bowels  are  regularly  emptied 
and  that  the  gas  does  not  accumulate  in  the  intestines. 
The  binder  after  labor  does  not  prevent  “high  stomach/’ 
and  while  the  writer  recommends  it  (see  Treatment  of 
the  Puerperium),  the  most  benefit  obtained  from  it  is 
when  the  patient  first  leaves  the  bed.  To  bring  the 
abdominal  walls  back  to  their  original  tonus  the  nurse 
may,  after  the  uterus  has  shrunk  into  the  pelvis,  give 
them  a daily  five-minute  massage. 

To  prevent  the  overstretching  of  the  skin  and  the 
formation  of  the  lineae  or  striae  gravidarum,  our  efforts 
are  not  very  successful,  but  the  writer  recommends 
albolene  as  an  inunction.  Several  such  remedies  are 
much  vaunted  in  newspaper  advertisements.  Massage 
of  the  skin  with  oil  or  fat  does  help  prevent  striae. 

Women  whose  legs  become  swollen  and  full  of  im- 
mense varicose  veins  should  wear  rubber  stockings. 
This,  in  its  marked  form,  is  a congenital  defect  and  un- 
preventable. 

The  Diet.  —The  diet  of  the  pregnant  woman  should 
be  simple,  but  not  strict.  The  amount  of  meat  and 
broths  should  be  small — meat  once  a day  only.  Starches 
fried  in  fat  and  rich  pastry  should  be  avoided.  Other- 
wise a liberal  diet  may  be  allowed,  especially  plenty  of 
water,  milk,  and  all  the  milk-products.  Cereals,  fruits, 
and  vegetables  should  be  eaten,  especially  fruit,  to  loosen 
the  bowels.  Women  sometimes  reduce  the  food  taken 
in  the  last  three  months  with  the  idea  of  restraining  the 
growth  of  the  child.  This,  if  overdone,  is  unwise.  Cer- 
tain books  advise  a special  diet  to  reduce  the  bone  salts 
in  the  skeleton  of  the  fetus  and  thus  insure  an  easy  labor. 
It  is  questionable  if  the  desired  effect  could  be  ob- 
tained without  first  injuring  the  mother,  and,  further, 
the  child  would  probably  suffer  from  rickets.  In  women 
with  contracted  pelves  a specially  restricted  diet  has 


EXERCISE 


8l 


been  tried  with  a view  to  restraining  the  development 
of  the  child  and  thus  insuring  its  passage;  the  results 
are  not  certain.  (See  p.  452.)  On  the  other  hand, 
the  gravida,  thinking  she  must  feed  two  persons,  must 
not  overeat.  She  should  be  advised  that  her  usual 
habits  should  continue  in  pregnancy. 

No  wine  or  other  alcoholics  may  be  taken,  first, 
because  of  the  danger,  exaggerated  during  pregnancy, 
of  contracting  the  liquor  habit;  second,  because  of  a 
demonstrable  bad  effect  on  the  offspring.  The  evil 
effects  of  alcoholics  on  the  infant  were  recognized  even 
in  biblical  times.  It  is  said  that  Samson’s  mother  ab- 
stained from  wine  during  her  pregnancy.  A child 
conceived  while  the  father  is  intoxicated  may  be  dull, 
stupid,  or  diseased.  Diogenes  was  aware  of  this  fact, 
which  recent  experiments  on  guinea-pigs  have  proved. 

Exercise. — A moderate  amount  of  exercise  must  be 
taken  each  day,  but  the  patient  should  always  stop 
short  of  fatigue.  A woman  cannot  develop  muscle 
during  pregnancy  to  make  labor  easier;  she  should  have 
done  this  before.  If  active  exercise  tires  her  too  much, 
a general  massage  may  be  given,  always  avoiding  the 
breasts,  the  abdomen,  and  the  veins.  Walking  in  the 
open  air  and  in  the  sunlight  must  be  urged,  always,  of 
course,  short  of  fatigue.  No  golf,  tennis,  dancing,  or 
swimming  is  permissible  during  pregnancy.  Sewing 
on  the  machine  should  be  restricted. 

The  patient  may  go  to  the  theater,  but  must  avoid 
crowds  for  fear  of  getting  into  a crush.  She  must 
avoid  gatherings  in  close  rooms,  especially  with  stove- 
heat,  because  of  the  danger  of  coal-gas,  etc.,  injuring 
the  child.  She  should  not  travel  much,  and  if  travel  is 
necessary,  should  go  in  the  most  comfortable  way  ob- 
tainable. If  a patient  has  a history  of  abortions  or  a 
known  tendency,  travel  should  be  prohibited.  Long 
6 


82 


the  hygiene  of  pregnancy 


trolley  rides  may  bring  on  premature  labor,  and  the  same 
may  be  said  of  automobile  riding  on  rough  roads. 

The  Mind  During  Pregnancy  and  Maternal 
Impressions.  —The  pregnant  woman  should  lead  a 
placid,  quiet  life,  avoiding  mental  as  well  as  physical 
fatigue  and  excitement.  The  patient  should  read  good 
books  and  avoid  medical  subjects.  It  is  not  necessary 
for  her  to  be  acquainted  with  the  processes  of  labor  and 
its  various  complications.  From  medical  books  pub- 
lished for  the  laity  she  will  obtain  erroneous  impressions 
regarding  the  function,  and  groundless  fears  will  be  en- 
gendered in  her  mind.  J “ Maternity,”  by  Dr.  Henry  D. 
Fry,  may  be  recommended,  as  may  also  “Woman  and 
Marriage,”  by  Margaret  Stephens. 

The  patient  must  not  be  allowed  to  worry  over  her 
condition  and  her  approaching  labor.  So  far  as  possible 
she  should  be  removed  from  association  with  gossiping 
neighbors,  who  take  pleasure  in  recounting  the  diffi- 
culties and  dangers  of  parturition,  and  the  relation  of 
wonderful  cases — and  the  nurse  must  not  be  guilty  of 
the  same  offense. 

If  there  is  a tendency  to  melancholia,  the  physician  is 
to  be  informed  of  it.  A change  of  scene  may  be  ordered. 
There  is  a popular  notion,  handed  down  from  the  ages, 
that  a woman’s  condition  of  mind  may  influence  her 
unborn  child  mentally  and  physically. 

Statistics  tend  to  prove  that  the  mothers  of  great  men 
nearly  always  were  characterized  by  great  intelligence, 
superior  intellectual  attainments,  or  religious  devotion, 
and  that  great-minded  fathers  less  often  procreated  chil- 
dren that  became  great.  The  evil  effects  of  alcoholism 
during  pregnancy  have  already  been  alluded  to. 

Most  physicians  do  not  believe  that  the  state  of  the 
mother’s  mind  during  pregnancy  can  affect  the  fetus. 
They  base  this  disbelief  on  the  fact,  which  cannot  be 


THE  DETERMINATION  OF  SEX 


33 


doubted,  that  there  exists  no  connection,  either  nervous 
or  vascular,  between  the  child  and  its  mother.  That  a 
fright  or  shock  can  so  alter  the  milk  of  a nursing  mother 
that  the  nursling  may  be  seized  with  convulsions  is  a 
fact.  Reasoning  from  analogy,  one  would  believe  that 
the  same  effect  could  be  produced  on  the  child  in  the 
uterus.  A fright  or  shock  may  bring  on  abortion  or 
premature  labor  by  causing  a hemorrhage  in  the  placenta. 

If  a woman  believes  that  by  reading  good  books  her 
child  will  be  intellectual;  that  by  studying  good  pic- 
tures and  sculpture  her  child  will  be  artistic;  that  by 
engaging  in  the  science  of  mechanics  her  child  will  be 
mechanical,  the  belief  may  be  encouraged,  as  it  conduces 
to  the  general  welfare  of  both,  even  though  there  is  no 
scientific  basis  for  the  belief. 

That  a fright,  such  as  seeing  an  ugly  object  or  de- 
formity, will  produce  a like  deformity  in  the  unborn 
child  is  not  scientifically  proved.  Cases  reported  in 
evidence  of  such  effect  can  usually  be  explained  by  coin- 
cidence, if  untruthfulness  be  excluded.  The  fetus  is 
completely  formed  at  the  eighth  week,  and  the  shock  or 
impression  to  which  the  deformity  is  usually  ascribed 
almost  always  occurs  after  this  time. 

The  limits  of  this  book  do  not  permit  the  presentation 
of  the  many  theories  and  reasons  for  and  against  the 
proposition,  but  suffice  it  to  say  that  the  nurse  may 
comfort  the  mother  with  the  statement  that  maternal 
impressions  do  not  affect  the  physical  well-being  of  the 
child. 

The  Determination  of  Sex.-4^Even  if  it  were  pos- 
sible, it  is  doubtful  if  it  would  be  desirable  that  parents 
be  able  to  influence  the  sex  of  the  unborn  child.  We  do 
not  know  what  causes  produce  the  two  sexes  in  the 
ratio  of  106  males  to  100  females,  a ratio  that  obtains 
the  world  over. 


84 


THE  HYGIENE  OF  PREGNANCY 


Many  investigators  have  studied  the  subject  and  end- 
less theories  have  been  propounded,  but  nature  still 
hides  the  secret  of  the  production  of  sex.  As  far  as  we 
know  at  present,  the  sex  of  the  child  is  already  deter- 
mined in  the  ova  in  the  ovaries  of  the  girl,  even  before 
puberty,  and,  therefore,  no  external  influences  can  affect 
the  sex  of  the  infant  during  pregnancy.  It  is  a matter  of 
chance  whether  a male  or  a female  ovum  is  the  one  to  be 
fertilized  by  the  male  element.  The  subject  is  by  no 
means  closed,  and  perhaps  nature  will  give  up  her  secret 
in  time. 

To  diagnose  whether  a male  or  a female  child  will  be 
born  is  also  beyond  our  ken.  All  statements  in  this 
regard,  it  must  be  admitted,  are  guesses.  The  rapidity 
of  the  fetal  heart-tones  may  be  used  as  a basis  of  the 
guess.  If  the  child’s  heart  beats  faster  than  140  a 
minute,  we  say  a girl  will  be  born;  if  below  130,  a boy, 
leaving  the  intervening  numbers  as  of  doubtful  signifi- 
cance. 

The  Bowels. — Attention  to  the  intestinal  tract  during 
pregnancy  is  of  the  utmost  importance  because  most 
serious  consequences  may  be  the  cost  of  the  neglect  of 
the  same.  Most  women  -perhaps  9 out  of  10 — are 
costive  during  pregnancy,  and  the  relief  of  chronic  con- 
stipation requires  great  effort,  patience,  and  persistence. 
A long-standing  habit  cannot  be  cured  during  pregnancy, 
and  usually  we  must  resort  to  medicines,  but  they  are 
always  avoided  if  possible.  The  general  rules  for  curing 
constipation  are  the  same  during  pregnancy  as  out  of  it, 
and  are  as  follows: 

__  1 . Have  the  patient  make  it  an  unfailing  habit  to  go  to 
stool  at  a certain  hour  each  day.  Usually  the  best  time 
is  shortly  after  breakfast.  Should  no  movement  occur 
at  the  time — and  straining  is  not  permitted — the  action 
of  the  rectum  may  be  provoked  by  a glycerin  sup- 


THE  BOWELS 


85 


pository  or  an  enema.  As  the  habit  is  established,  these 
means  are  omitted.  She  must  never  resist  the  desire  to 
go  to  stool  at  any  time. 

2.  Every  morning,  just  after 
rising,  and  every  evening,  just 
before  retiring,  the  patient 
should  drink  a glass  of  cool 
water  and  eat  some  fruit — an 
apple  or  an  orange.  Between 
meals  she  should  drink  water 
freely. 

3.  Her  diet  should  contain 
fruit  and  vegetables  in  abun- 
dance, especially  spinach,  peas, 
beans,  barley,  tomatoes,  corn, 
and  foods  of  this  kind.  No  tea 
is  allowed,  but  a little  coffee 
may  be  taken  at  breakfast.  To 
the  diet  may  be  added  bran 
and  molasses  biscuits,  of  which 
there  are  several  kinds  on  the 
market. 

4.  Every  night  before  retiring 
let  the  patient  inject  into  the 
rectum  6 to  8 ounces  of  com- 
mon olive  oil  by  means  of  a 
hard-rubber  syringe  and  catheter 
(Figs.  39,  40).  The  oil  remains 
over  night  in  the  rectum,  soothes 
the  mucosa,  and  allays  a possible 

spasm  of  the  bowel.  In  the  morning  the  bowels  will 
move  or  may  be  aided  by  a plain  water  enema. 

If  these  rules  prove  insufficient,  let  the  patient  eat 
prunes,  figs,  and  dates,  warning  her  to  chew  them  very 
thoroughly.  It  is  good  that  the  patient  have  some 


Fig.  39. — Tin  funnel  with  rec- 
tal tube  for  oil  enemata. 


86 


THE  HYGIENE  OF  PREGNANCY 


system  about  this,  for  example,  that  she  begin  eating 
one  prune  the  first  day,  increasing  one  each  day  up  to 
ten,  then  decreasing  to  one,  then  up  again.  There  is  a 
little  mental  suggestion  in  this.  If  the  patient  is  not 
pregnant,  abdominal  massage  may  be  practised,  and  the 
results  are  usually  good. 

If  constipation  persists  we  resort  to  drugs,  and,  of 
them  all,  fluidextract  of  cascara  sagrada  ( Rhamnus 
purshiana)  is  the  best.  Alternate,  after  a month’s  use, 
with  Pluto  water  or  other  saline  laxative  and  phenol- 
phthalein,  all,  of  course,  with  the  physician’s  order. 


Fig.  40. — Hard-rubber  syringe  and  soft-rubber  rectal  tube  (small)  for  oil  enemata. 


Enemata  are  useful  only  for  temporary  relief,  not  for 
daily  and  continuous  employment,  because  they  dilate 
and  weaken  the  bowel  and  may  irritate  it.  The  cascara 
should  be  given  in  increasing  doses,  like  the  prunes,  in- 
creasing 1 drop  each  day  up  to  30  drops,  then  decreas- 
ing. The  bitter  extract  is  the  best,  administered  in 
capsules;  5-grain  empty  capsules  are  filled  with  the 
medicine  in  proper  dosage  just  before  it  is  taken. 

The  Kidneys.  -These  organs  are  generally  conceded 
to  be  the  weak  spot  during  pregnancy,  and,  therefore, 
they  require  particular  watching  and  care.  The  urine 
should  be  examined  every  three  weeks  during  pregnancy, 
and  oftener  if  there  is  any  reason  to  suspect  trouble. 
The  test  should  be  made  for  albumin,  sugar,  specific 


gravity,  the  amount  of  urea,  and  microscopically  for 
casts,  etc.  The  total  amount  passed  in  twenty-four 
hours  is  of  utmost  importance — it  should  be  at  least 
50  ounces.  If  there  are  casts  or  albumin,  the  case  is 
usually  one  of  nephritis,  or  should  be  considered  such, 
and  danger  apprehended.  The  physician  should  also  be 
notified  if  not  enough  urine  is  passed.  Edema  of  the 
feet  and  swelling  of  the  hands  and  eyelids  are  always 
significant,  though  they  need  not  come  from  kidney  dis- 
ease, and  should  be  reported  to  the  physician. 

Toxemia. — There  is  a condition  found  during  preg- 
nancy due  to  improper  functioning  of  internal  organs 
or  insufficient  elimination  from  the  organs  of  excre- 
tion; it  is  called  toxemia,  and  produces  symptoms 
from  the  stomach,  as  hyperemesis  gravidarum  or  ex- 
cessive vomiting;  symptoms  from  the  brain,  as  eclamp- 
sia, persistent  headache,  etc.  The  patient  should  take 
care  of  her  kidneys,  and  follow  the  rules  laid  down 
under  Dress,  Diet,  Bathing,  and  Bowels,  which  have 
the  health  of  these  organs  in  view.  (See  chapter  on 
Complications.) 

Bathing-. — The  skin  during  pregnancy  is  more  ac- 
tive than  usual  and  requires  more  care:  first,  to  avoid 
chilling;  second,  to  keep  up  its  function  as  an  excretory 
organ. 

The  patient  should  bathe  daily  or  often  during  the 
week.  The  bath  should  be  tepid — 88°  to  90°  F.  Cold 
bathing,  cold  plunges,  cold  showers,  sitz-baths,  ocean 
bathing,  and  hot  baths  are  all  proscribed  during  preg- 
nancy. Abortion  has  repeatedly  been  caused  by  surf- 
bathing. If  the  kidneys  are  not  acting  well  the  phy- 
sician may  prescribe  warm  (98°  F.)  baths,  followed  by 
sweating  in  bed.  After  the  bath  the  gravida  must  avoid 
chilling  the  skin. 

For  the  sometimes  profuse  perspiration  a tepid  bath 


88 


THE  HYGIENE  OF  PREGNANCY 


Fig.  41. — Sanitary  seat  cover.  Take  a piece  of  tissue  paper,  15  x 20  inches, 
fold  as  in  1,  cut  as  in  2.  The  center  (3)  is  laid  on  the  water  in  the  closet  bowl 
to  prevent  splashing;  the  large  piece  (4)  covers  the  seat.  After  use  it  is  cast 
into  the  bowl.  Several,  folded  like  5,  should  be  carried  while  traveling. 


followed  by  a vigorous  rub  with  a “salt  towel”  is  effica- 
cious. A salt  towel  is  made  by  wringing  a coarse  bath 


CARE  OF  THE  BREASTS 


89 


towel  out  of  a strong  salt  solution  and  drying  it.  In  the 
week  before  labor  and  during  labor  the  tub-bath  had 
better  not  be  employed,  because  of  the  danger  of  the 
wash- water  gaining  entrance  into  the  vagina.  The 
shower-bath  must  be  substituted.  This  advice  is  espe- 
cially needed  for  multipart. 

Care  of  the  Genitals. — Since  the  secretions  from 
the  genitals  are  augmented — leukorrhea  being  a common 
complaint — daily  ablutions  of  the  parts  are  essential 
to  keep  them  free  from  eczematous  eruptions  and  to 
avoid  odor. 

Multipart,  especially,  because  of  the  patency  of  the 
introitus,  may  contract  infections  of  the  vulva  and 
vagina  from  street  dust  and  by  contact  with  dirty  water- 
closet  seats.  The  patient  is  instructed  to  wear  closed 
drawers,  certainly  in  the  later  months  of  pregnancy,  and 
she  should  provide  herself  with  sanitary  seat  covers  for 
use  when  away  from  home  (Fig.  41). 

If  the  vulva  is  enlarged  by  varicose  veins,  the  woman 
must  be  instructed  to  avoid  injury  which  might  cause  a 
fatal  hemorrhage. 

Care  of  the  Breasts. — The  breasts  require  care 
from  early  girlhood  to  fit  them  for  the  important  func- 
tion of  lactation.  It  is  a great  misfortune  if  a woman  can- 
not nurse  her  infant,  and  no  effort  should  be  spared  to 
prevent  such  a calamity.  From  the  time  of  puberty 
the  growing  organs  should  be  protected  from  pressure, 
so  that  the  whole  gland  may  develop  properly.  At  all 
times  and  especially  during  athletic  exercises  care  should 
be  taken  to  avoid  injury  Mothers  should  be  taught  to 
provide  for  the  development  of  the  reproductive  organs 
of  their  girls  as  well  as  for  the  development  of  their 
brains. 

During  pregnancy,  if  the  breasts  are  large  and  heavy, 
some  form  of  supporter  should  be  used.  The  surface 


9o 


THE  HYGIENE  OF  PREGNANCY 


should  be  washed  daily  with  soap  and  warm  water,  using 
care  to  remove  the  branny  scales  from  the  nipples,  and 
then  the  latter  anointed  with  cocoa-butter  or  albolene. 
In  blondes  with  very  tender  skin  the  following  lotion 
may  be  applied  to  the  nipples  each  morning  for  a week,  to 
be  followed  by  the  use  of  albolene  for  a week: 


1$.  Glycerite  of  tannin \ ounce; 

Compound  spirit  of  lavender i “ 

Water 3 ounces. 


No  strongly  astringent  washes  or  alcohol  should  be  used; 
the  nipples  must  not  be  hardened,  but  rather  kept 
soft  and  pliable.  The  nipples  should  be  relieved  of  all 
compression.  If  they  are  flat,  gentle  attempts  to  draw 
them  out  may  be  made  night  and  morning.  The 
breasts  should  at  all  times  be  protected  from  injury, 
which  some  time  later  might  become  the  starting-point 
of  a mastitis. 

The  Engagement  of  the  Nurse. — The  author  be- 
lieves that  obstetric  nursing  requires  higher  skill  than 
any  other  form  of  nursing,  comprising,  as  it  does,  sur- 
gical, medical,  and  infant  nursing.  It  is  more  arduous, 
surely.  For  these  reasons  only  the  best  nurses  should 
adopt  this  specialty,  and  the  author  believes  the  re- 
muneration should  be  higher  than  for  work  in  the  other 
branches  of  the  profession.  An  obstetric  nurse  should 
not  take  infectious  cases.  She  should  allow  sufficient 
time  between  engagements.  It  is  better  for  the  nurse 
to  be  at  the  house  a few  days  or  a week  before  the  day  of 
labor,  but  most  women  prefer  to  wait  until  labor  has 
begun  before  sending  for  the  nurse,  which  is  a very  un- 
comfortable way,  since  this  keeps  the  nurse  waiting  at 
her  home  and  she  may  not  be  accessible  when  wanted. 
Occasionally  an  arrangement  is  made  whereby  the  nurse 
remains  at  her  home  for  a stated  time  before  the  labor, 


LIST  OF  ARTICLES  FOR  OBSTETRIC  CASES  9 


being  paid  by  agreement  half  or  full  salary.  It  is  wise 
to  have  such  agreements  made  in  writing,  though  it  is 
not  customary.  The  time  a nurse  is  called  depends,  of 
course,  upon  the  time  set  for  the  confinement,  and  since 
this  can  never  be  determined  accurately,  the  nurse 
seldom  knows  when  she  will  be  summoned.  A certain 
date  is  usually  agreed  upon,  from  which  time  the  nurse 
awaits  a call.  The  nurse  may  take  short,  clean  cases  up 
to  this  date,  or,  if  they  promise  to  run  over  the  day  of 
her  obstetric  engagement,  with  the  stipulation  that  she 
will  be  allowed  to  leave  when  the  call  comes. 

The  patient  is  usually  supplied  by  the  doctor  with  a 
list  of  articles  to  get.  This  list  is  one  furnished  to  his 
patients  by  the  writer: 

List  of  Articles  for  Obstetric  Cases 

2 hand-basins  of  graniteware,  medium  size. 

2 hand-brushes,  wooden  backs. 

i new  2-quart  douche-bag. 

1 “Perfection”  bed-pan. 

Rubber  sheeting  enough  to  cover  the  bed  and  a 
piece  a yard  square. 

30  yards  of  bleached  dairy  cloth. 

2 pounds  of  aseptic  absorbent  cotton. 

5 -yard  jar  borated  gauze. 

100  bichlorid  of  mercury  tablets. 

4 ounces  of  lysol. 

4 ounces  of  boric  acid  crystals. 

1 ounce  of  camphorated  oil. 

2 ounces  solid  albolene. 

One  rubber  catheter,  size  14  French  scale. 

Water  pitchers  and  vessels  for  the  storing  of  sterilized 
water,  if  not  in  the  house,  should  be  procured. 


92 


THE  HYGIENE  OF  PREGNANCY 


INSTRUCTIONS  FOR  THE  OBSTETRIC  NURSE 


Sterilising.  — A few  weeks  before  the  labor  the 
nurse  should  go  to  the  patient’s  house  and  sterilize  the 
following  articles: 

1.  Six  sheets. 

2.  Two  dozen  towels,  old  and  soft  ones,  but  without 
holes. 

3.  Six  pillow-cases. 


vr 


r 


(NJ 


^rp  e^v 


9" 

Fig.  42. — T-binder  or  pad-holder. 


) 


J 


4.  Four  abdominal  binders.  These  are  of  unbleached 
cotton  cloth,  16  inches  wide  and  36  inches  long,  doubled 
and  hemmed. 

5.  Four  “pad-holders”  or  T-bandages,  similar  to  the 
menstrual  pad-holder  (Fig.  42). 

6.  Three  breast-binders  of  the  size  and  shape  given 
herewith  (Fig.  43). 


INSTRUCTIONS  FOR  THE  OBSTETRIC  NURSE  93 


7.  Two  night-dresses,  of  the  smoking- jacket  pattern 
for  the  mother,  or  two  of  the  confinement  jackets  illus- 
trated here  (Fig.  44). 


Fig.  44. — Jacket  used  during  confinement.  Chicago  Lying-in  Hospital  pattern. 


94 


THE  HYGIENE  OF  PREGNANCY 


8.  Two  pairs  of  long  stockings  for  the  mother,  so- 
called  “opera  lengths/’  or,  if  obtainable,  the  obstetric 
leggings  illustrated  here  (Fig.  45). 

9.  Two  men’s  gowns  or  surgical  gowns,  for  the  hus- 
band, if  he  is  to  be  in  the  lying-in  chamber,  and  the 
anesthetizer. 

10.  Two  obstetric  pads  of  absorbent  cotton,  1 inch 
thick  and  1 yard  square,  covered  on  each  side  with  gauze, 
and  tacked.  In  lieu  of  these  some  nurses  use  squares  of 
mattress  pad  material;  4^  yards  make  six  pads.  After 
delivery  these  are  washed  and  then  are  suitable  for  the 
baby’s  bed.  Four  thicknesses  of  newspaper  wrapped  in 
a bath  towel  make  an  excellent  pad. 


11.  Several  dozen  ordinary  menstrual  pads  of  cotton, 
covered  with  gauze,  and  which  are  long  enough  to  be 
pinned  to  the  binder  before  and  behind. 

12.  A pillow-case  full  of  sterile  cotton  pledgets,  the 
size  of  a lemon,  for  use  as  sponges  during  labor.  These 
are  cheap  and  good. 

13.  One  Mason  jar  full  of  applicators,  cotton  wound 
on  tooth-picks  (Fig.  46). 

14.  Two  Mason  jars  of  gauze  pledgets  for  perineor- 
rhaphy and  cord  dressings  should  also  be  very  carefully 
sterilized.  Covered  sponges,  described  on  page  434,  are 
excellent  for  perineorrhaphy,  are  cheaper  than  gauze, 
and  as  good. 

Each  package  should  be  neatly  covered  with  napkins 


INSTRUCTIONS  FOR  THE  OBSTETRIC  NURSE  95 


and  distinctly  labeled,  so  that  confusion  may  be  avoided 
at  the  time  of  labor. 

After  thorough  sterilization  and  drying,  they  should 
be  packed  carefully  away  and  protected  from  dust. 

The  basins,  brushes,  douche-bag,  and  pitchers  should 
all  be  sterilized  and  put  away  aseptically,  so  as  to  be 
ready  for  use  in  case  of  emergency.  (See  page  424  for 
Methods  of  Sterilizing.) 

Sterilization  is  best  accomplished  by  steam,  and  there 
are  several  instruments  on  the  market  doing  good  work. 
The  Rochester,  Arnold,  or  Boeckman  sterilizer,  with 


Fig.  46. — Cotton-wrapped  tooth-picks,  known  as  applicators. 


proper  management,  does  equally  as  good  work  as  the 
large  high-pressure  apparatus. 

Maternity  boxes  may  be  purchased  from  the  medical 
supply  houses  at  prices  varying  from  $5  to  $20.  They 
contain  the  various  articles  required,  all  sterilized,  ready 
for  use. 

The  Nurse’s  Visit. — It  is  a good  plan  for  the  nurse 
to  call  on  the  patient  occasionally  during  the  pregnancy. 
The  young  mother  will  need  instruction  regarding  her 
dress,  diet,  and  mode  of  life.  The  baby’s  layette  will 
also  be  a subject  for  discussion. 


9<5 


THE  HYGIENE  OE  PREGNANCY 


The  nurse  may  do  much  to  encourage  the  patient  for 
her  approaching  trial,  and  give  her  advice  regarding  the 
health  of  both  mother  and  child. 

She  should  acquaint  the  patient  with  the  phenomena 
of  beginning  labor,  so  that  the  physician  may  be  notified 
promptly,  and  tell  her  what  to  do  if  the  baby  should 
come  very  quickly. 

The  nurse  may  discover  some  dangerous  complication 
threatening,  as  eclampsia  or  placenta  praevia,  and  will 
notify  the  attending  accoucheur. 

The  patient  should  be  instructed  to  take  no  douches, 
and  not  to  insert  the  finger  in  the  parts,  during  the  latter 
weeks  of  pregnancy. 


CHAPTER  VI 


THE  INFANT'S  LAYETTE 

The  nurse, is  often  consulted  by  the  young  mother 
regarding  the  baby’s  layette.  This  list  is  intended  sim- 
ply to  guide  her  in  the  selection  of  the  needed  articles.1 

THE  WARDROBE 

Six  straight  hands , 18  inches  long  and  5 inches  wide, 
made  of  flannel,  with  the  edges  pinked,  not  hemmed. 
These  will  be  used  for  the  first  two  months. 

Six  knit  hands  with  shoulder-straps,  of  silk  and  wool 
for  a winter  baby,  of  cotton  for  a summer  baby.  These 
bands  will  lose  their  elasticity  with  the  first  washing  and 
become  useless  unless  they  are  properly  dried.  They 
must  not  be  hung  up  to  dry  or  laid  out  flat.  After 
washing  and  rinsing  they  should  be  wrung  out  by  hand, 
tightly,  and  left  in  that  tight  roll  to  dry,  near  a fire. 

Six  knit  shirts , of  silk  and  wool  for  winter,  of  cotton 
for  summer.  It  is  better  to  get  the  second  size,  as  the 
first  size  is  outgrown  in  a few  weeks. 

Six  pinning  blankets  for  a winter  baby;  they  are  not 
necessary  in  summer.  These  should  be  made  entirely  of 
flannel.  A piece  24  inches  square  may  be  sewed  onto  a 
flannel  band  (18  by  6 inches)  in  flat  plaits,  allowing  the 
band  to  project  2 inches  at  each  end. 

Six  flannel  skirts  for  a winter  baby. 

Eight  flannel  skirts  for  a summer  baby,  four  for  day 
and  four  for  night.  (A  winter  baby  wears  a skirt  and 

1 This  chapter  was  written  by  Miss  Katherine  DeWitt. 

7 97 


98 


THE  INFANT'S  LAYETTE 


stockings  by  day,  a pinning  blanket  and  socks  at  night. 
A summer  baby  wears  skirts  by  day  and  night,  except 
in  very  hot  weather,  when  a shirt  band,  diaper,  and 
dress  or  night-dress  are  sufficient.)  lire  skirts  should 
be  made  with  a waist,  either  of  flannel  or  of  muslin,  or 
they  may  be  cut  all  in  one  piece,  after  a Gertrude  or 
princess  pattern.  In  any  case  the  skirt  must  be  sup- 


Fig.  47. — Infant’s  dress  for  the  first  weeks.  Back  view. 


ported  from  the  shoulders  and  must  open  in  the  back, 
so  that  it  may  be  put  on  with  the  dress. 

Four  dresses  of  the  Warren  pattern  (Fig.  47).  These 
are  made  of  light-weight  twilled  flannel,  are  sleeveless, 
open  at  the  bottom,  and  have  a single  slit  at  the  back  of 
the  yoke.  This  dress  is  especially  valuable  for  hospital 
work.  It  keeps  the  hands  warm  and  prevents  the  child 


THE  WARDROBE 


99 


from  scratching  its  face  and  infecting  its  eyes.  It  is 
easily  and  quickly  changed.  For  the  first  two  weeks  of 
life  it  is  highly  recommended,  and  subsequently  as  a 
night-dress.  For  summer  use  they  may  be  made  of  fine 
Canton  flannel. 

Twelve  dresses , not  more  than  i yard  long  from  neck 
to  hem.  These  may  be  made  by  any  simple  “slip” 
pattern  or  with  a yoke.  They  should  be  simple,  as 
they  are  prettier  and  more  comfortable  when  not  loaded 
with  ruffles  or  embroidery.  Very  narrow  lace  or  inser- 
tion, fine  tucking,  hem-stitching,  and  feather-stitching 
are  the  most  attractive  trimmings. 

Six  night-dresses  of  light-weight  twilled  flannel — some- 
thing almost  as  light  as  cashmere,  made  by  a “slip” 
pattern.  These  should  be  of  good  size,  as  the  baby  will 
wear  long  night-dresses  after  being  put  into  short  clothes. 

Six  pairs  of  white  woolen  stockings  for  a winter  baby. 

Six  pairs  of  socks. 

Six  dozen  diapers  of  cotton  diaper-cloth.  This  should 
be  shrunk  before  the  diapers  are  cut  off,  otherwise  they 
will  not  fold  square.  They  should  be  made  twice  as 
long  as  they  are  broad,  and  should  be  of  two  sizes, 
medium  (20  by  40  inches)  and  large  (26  by  52  inches). 

Two  dozen  cheese-cloth  diapers , made  of  1 yard  of 
cheese-cloth  folded  twice,  so  that  the  diaper  is  J yard 
square  and  has  four  thicknesses.  These  are  just  the 
right  size  for  first  diapers,  and  are  soft  without  ironing. 
They  can  be  used  for  inside  diapers  later.  They  should 
be  stitched  around  the  edges  and  diagonally. 

Several  blankets  for  wrapping  about  the  baby,  made 
of  flannel,  cashmere,  or  knit  of  wool.  The  last  are  by 
far  the  best.  A good  size  is  1 yard  square  for  cash- 
mere  or  flannel,  1 yard  by  ij  yards  for  the  knit  ones. 

The  baby’s  outdoor  garments  can  be  provided  after 
its  arrival. 


IOO 


THE  INFANT'S  LAYETTE 


NURSERY  CONVENIENCES 

The  Bed. — This  may  be  a wicker  bassinet,  a large 
clothes-basket  (which  is  quickly  outgrown),  or  a crib. 
Whatever  is  used  as  a bed,  should  be  provided  with  a 
hair  mattress.  A baby  who  sleeps  with  a bed-pillow 
under  its  body  and  a down  pillow  under  its  head  is  lying 
with  its  spine  curved  and  is  being  kept  much  too  warm, 
so  that  it  will  easily  take  cold  or  have  earache.  The 


Fig.  48. — Best  infant  scales. 


hair  mattress  should  be  covered  with  a square  of  rubber 
sheeting,  then  with  a square  of  mattress  covering,  1 
yard  each  way.  The  mattress  covering  can  be  bought 
by  the  yard,  and  four  pads  will  be  needed.  Over  the 
mattress  pad  a cambric  sheet  is  laid ; have  six  of  these  on 
hand — they  are  used  under,  but  not  over,  the  baby. 
They  should  be  made  large  enough  to  tuck  under  the 
mattress  well  on  all  sides. 

For  covering,  one  may  have  two  light-weight  blankets 


NURSERY  CONVENIENCES 


IOI 


made  of  flannel,  bound  with  wash-ribbon,  and  two  light 
comforters  made  of  cotton  or  wool,  covered  with  cheese- 
cloth, silkaline,  or  silk,  and  tied  with  silk  floss  or  ribbon. 
A hair-pillow  with  four  cases  made  of  linen  should  be 
provided,  though  the  baby  should  not  sleep  on  it  until 
he  is  six  months  old. 

Good  scales  (Fig.  48).  The  fancy  infant  scales  are  not 
reliable.  The  best  scale  is  the  ordinary  grocer’s  even 
balance,  with  iron  weights  for  the  pounds  and  a bar  for 
the  ounces. 

A bath-tub  of  rubber,  white  enamel,  or  papier-mache. 

Small-sized  clothes-bars.  These  will  be  used  for  airing 
the  baby’s  clothes  and  holding  its  towels. 

Two  bath  aprons  of  flannel  (38  by  27  inches),  made 
with  a hem  top  and  bottom.  Through  the  upper  hem  a 
wash-ribbon  is  run  to  tie  about  the  waist. 

Six  old  soft  damask  towels.  If  these  cannot  be  ob- 
tained, nice  baby  towels  can  be  made  from  linen  diaper- 
cloth,  but  they  should  be  frequently  scrubbed  and  boiled 
to  make  them  soft. 

A wicker  hamper  or  shallow  basket,  lined  with  muslin 
and  holding  the  following  toilet  articles: 

6 washcloths  of  shaker  flannel,  6 inches  square. 

1 small  soft  sponge. 

1 cake  of  old  Castile  soap. 

1 bath  thermometer. 

1 tube  albolene  (solid). 

1 comb  and  brush. 

3 dozen  safety-pins,  three  sizes. 

Powdered  stearate  of  zinc  in  shaker. 

A package  of  applicators  (tooth-picks  wound  with 
cotton).  (See  Fig.  46.) 

1 jar  sterile  navel  dressings. 

Small,  wide-mouthed  bottles  of  alcohol  and  boric  acid 
solution. 


102 


THE  INFANT'S  LAYETTE 


Bottle  of  pure  olive  oil  or  a jar  of  benzoinated  lard. 

Needle  and  thread. 

Several  old,  soft  handkerchiefs. 

Package  of  sterilized  cotton  sponges. 

Screen — not  a bamboo  screen  with  curtains  hung  on 
rods,  but  one  with  a firm  square  frame,  solidly  covered 
with  cretonne,  burlap,  or  denim,  so  that  it  affords  real 
protection  from  drafts  or  light. 

One  2-quart  hot-water  bag. 

A low  chair  without  arms. 

Two  hand-basins. 

The  nurse  will  find  this  list  quite  complete,  and  may 
select  from  it  the  articles  needed  as  far  as  the  patient’s 
circumstances  will  permit. 


PART  II 


NURSING  DURING  LABOR  AND  IN  THE 
PUERPERIUM 


CHAPTER  I 

CARE  DURING  LABOR 

How  will  the  nurse  tell  when  labor  begins?  First,  by 
the  show,  which  occurs  a few  hours  before  labor;  second, 
by  the  pains.  If  the  woman  complains  of  pains  first  in 
the  back,  then  drawing  around  to  the  front,  and  at  the 
same  time  the  uterus  hardens  (contracts),  and  if  these 
sensations  recur  at  gradually  lessening  intervals,  it  is  safe 
to  say  the  woman  is  in  labor.  Third,  by  the  dilatation  of 
the  os  uteri.  Fourth,  by  the  rupture  of  the  hag  of  waters. 
The  nurse  is  not  allowed  to  examine  the  patient  inter- 
nally without  instructions  from  the  physician.  The 
opening  of  the  os  is  the  most  certain  sign  of  labor. 
Without  an  internal  examination  the  best  observer  may 
make  a mistake  as  to  the  onset  of  labor,  since  the  patient 
may  have  “false  pains”  at  regular  intervals.  These  may 
lead  the  physician  to  think  the  woman  is  in  labor. 
Later  the  pains  subside  and  the  doctor  calls  the  episode 
a “false  alarm.”  The  subsidence  of  pain  may  even  occur 
after  some  dilatation  of  the  os  has  taken  place.  These 
uncertainties  are  very  annoying  to  patient,  doctor,  and 
nurse. 

Care  During  the  First  Stage.— As  soon  as  labor 
is  declared,  the  nurse  begins  to  surround  the  patient  with 

103 


104 


CARE  DURING  LABOR 


all  the  protective  measures  of  asepsis  and  antisepsis 
that  her  art  affords,  and  from  now  on  nothing  is  neglected 
that  will  save  the  patient  from  puerperal  infection. 

The  general  rules  of  asepsis  are  identical  with  those 
practised  in  the  most  particular  operating  room.  The 
care  to  be  observed  is  identical  with  that  observed  in  the 
course  of  a laparotomy,  because  the  danger  of  infection 
is  almost  equal  to  opening  the  abdomen.  The  diffi- 
culties in  attaining  obstetric  asepsis,  however,  are  greater 
than  in  surgery,  so  that  success  achieved  by  the  obstetric 
nurse  is  entitled  to  higher  credit. 

A woman  is  liable  to  infection  from  the  time  labor 
begins  until  she  has  been  up  and  around  a week.  Even 
before  and  after  this  time,  if  the  germs  introduced  are 
virulent,  she  may  be  infected.  A physician  returning 
from  a case  of  erysipelas  had  the  unfortunate  thought  to 
examine  his  wife,  who  had  been  delivered  seventeen  days 
before.  The  woman  died  a few  days  later  from  infection. 
A student,  in  examining  a woman  a few  days  before 
labor,  caused  a fatal  puerperal  infection. 

A nurse  doing  obstetric  nursing  should  keep  away 
from  infectious  cases,  and,  when  she  has  been  exposed, 
must  make  a complete  change  of  clothing,  take  a full 
bichlorid  bath,  and  shampoo  her  hair.  At  least  a week 
must  elapse  from  the  time  of  her  attendance  on  a pus 
or  scarlet  fever  case,  or  other  infectious  diseases,  before 
she  assumes  the  care  of  a parturient  woman.  During 
this  week  she  should  take  several  scrub  baths  and  sham- 
poo her  hair  carefully.  In  practice  it  is  hard  to  reconcile 
these  duties,  but  the  danger  is  too  great  to  neglect  such 
precautions.  Other  measures  will  be  considered  later 
under  the  heading  of  Puerperal  Infection.  It  might  be 
said  here  that  the  reasons  for  these  extra  precautions  in 
the  case  of  the  nurse  are  that  she  comes  into  such  inti- 
mate contact  with  the  mother  and  babe,  and  for  so  long  a 


CARE  DURING  THE  FIRST  STAGE 


05 


period  of  time,  and  so  often  during  the  day  has  to  treat 
both  surgically,  as  there  are  open  wounds.  It  is,  there- 
fore, highly  essential  that  she  be  aseptic. 

Preparation  of  the  Room. — The  sunniest  and  best 
room  in  the  house  should  be  selected  for  the  labor.  It 
should  be  near  the  bath-room,  and  should  be  properly 
heated.  Plenty  of  light  should  be  provided  at  night- 
time— a very  important  point.  The  room  should  be 
cleared  of  all  unnecessary  furniture.  Heavy  curtains 
and  all  bric-a-brac  should  be  removed.  If  there  is 
carpet  on  the  floor,  the  area  around  the  bed  should  be 
protected  by  a large  rubber  mackintosh  or  several  layers 
of  newspapers.  Rugs  should  be  removed  without  raising 
dust.  Two  plain  chairs,  a kitchen  table,  a sewing  table, 
and  a rocker  for  the  patient  complete  the  furniture.  In 
some  families  the  nurse  may  meet  objections  to  what  they 
term  unnecessary  preparations.  The  patient’s  mother 
perhaps  was  not  delivered  with  so  much  fuss  and  ado. 
Here  a little  tact  and  explanation  will  clear  the  way. 
One  cannot  force  advancement  on  the  people — one  must 
smooth  them  into  it. 

The  nurse  has  her  sterilized  things  at  hand,  usually  on 
the  dresser,  which  has  been  cleared  of  the  toilet  articles 
and  covered  with  a sheet.  She  has  a pitcher  of  hot,  and 
one  of  cold,  sterile  water,  each  covered  with  a hood,  in 
the  room.  The  wash-stand,  with  basin,  in  which  the 
physician  and  nurse  wash  their  hands,  should  be  thor- 
oughly scrubbed,  and  a new  piece  of  soap  placed  in  a 
clean  soap-dish.  This  wash-stand  and  soap  should  be 
reserved  for  the  physician  and  nurse.  A jar  of  sterile 
hand-brushes  and  a nail-file  complete  the  number  of 
articles  on  the  wash-stand. 

The  wall  around  the  table  on  which  the  hand  solu- 
tions are  set  should  be  protected,  using  a newspaper, 
so  that  the  decorations  will  not  be  marred,  and 


io6 


CAKE  DURING  LABOR 


throughout  the  case  the  nurse  should  exert  constant 
care  of  the  furniture  and  utensils  of  the  house,  so  that 
they  will  not  be  broken  or  injured  by  solutions,  by  hot 
basins,  etc. 

One  may  err  with  too  much  zeal,  therefore  the  nurse 
should  not  make  too  great  display  of  preparation,  which 
might  alarm  the  patient.  The  general  arrangement  of 
the  room  is  like  the  diagrams  (Figs  49,  50). 


Fig.  49. — Diagram  of  room  arranged  for  normal  confinement. 


Naturally,  one  will  not  always  find  conditions  in  prac- 
tice which  enable  one  to  arrange  everything  as  here 
given,  but  the  diagrams  will  show  what  is  needed  and 
how  things  may  be  conveniently  placed.  The  nurse 
who  knows  the  principles  of  asepsis  will  easily  adapt 
herself  to  the  exigencies  of  the  individual  case. 


CARE  DURING  THE  FIRST  STAGE 


O 7 


The  Preparation  of  the  Bed.  All  hangings  must  be 
removed  and  the  bed  wiped  with  i : 1000  bichlorid  solu- 
tion on  a damp  cloth.  The  foot  board  of  the  bed  is  to 
be  covered  with  a sheet,  pinned  securely  and  evenly. 
If  the  bed  has  a box-spring,  the  valance  should  be  re- 
moved or  pinned  up  securely;  then  the  side  of  the  spring 
should  be  covered  with  some  impervious  material  which 


Fig.  50. — Diagram  of  same  room  as  shown  in  Fig.  49,  arranged  for  operation. 


hangs  below  the  side  rails  or  boards.  Three  table  boards 
or  shelves  from  a bookcase  should  be  put  in  the  middle 
of  the  bed  between  the  mattress  and  the  spring,  so  as  to 
prevent  sagging  in  the  middle.  The  mattress  is  now 
covered  with  a rubber  sheet,  over  this  comes  a full  sheet, 
then  the  small  rubber  sheet,  on  this  a sheet  folded  once, 
the  draw-sheet  across  the  bed,  and  then  all  are  securely 


io8 


CARE  DURING  LABOR 


pinned  with  large  safety-pins.  The  patient  should  be 
warmly  covered,  depending  on  the  season.  In  winter 
she  may  need  a hot- water  bag  at  the  feet.  Occasionally 
one  applied  to  the  small  of  the  back  relieves  the  pains. 
The  sterile  sheets  are  put  on  at  the  first  if  there  is  a 
supply;  if  not,  the  bed  is  dressed  with  sterile  things  only 


Fig.  51. — Patient  across  the  bed,  with  preparations  for  the  internal  examina- 
tion. Sheet  used  to  drape  patient.  To  the  right  is  a sewing  table  with  anti- 
septic solutions. 


when  the  second  stage  draws  nigh.  The  nurse  should 
have  a clean  light  blanket  for  the  patient,  not  a soiled 
old  comforter.  The  best  in  the  house  is  not  too  good 
for  the  parturient. 

No  one,  unless  dressed  in  a sterile  gown,  may  sit  or 
lean  on  the  bed,  and  a sheet  or  pillow  that  has  fallen  on 
the  floor  must  not  be  put  back  on  the  bed.  When  a 


CARE  DURING  THE  FIRST  STAGE 


Og 


patient  is  delivered  on  the  side,  something  is  needed  to 
part  the  knees,  and  the  nurse  folds  a pillow,  covers  it 
with  newspapers,  and  then  pins  a sterile  pillow-slip 
securely  over  it.  (See  Fig.  61.) 

Preparation  of  Patient. — As  soon  as  the  patient  is 
known  to  be  in  labor,  the  bowels  must  be  thoroughly 
emptied  by  a soap-and-water  or  saline  flushing.  This 
must  be  repeated  once  or  twice  if  the  labor  is  slow  and 
long.  An  enema  may  not  be  given  in  the  second  stage 
without  the  doctor’s  permission.  The  nurse  must  pay 
strict  attention  to  the  bowels  and  bladder,  and  call 
the  accoucheur’s  notice  to  the  fact  that  either  is  not 
emptied  regularly.  The  parturient  should  void  urine 
every  four  hours,  and  if  she  does  not,  she  must  be 
catheterized. 

After  the  flushing  the  pudenda  are  shaved.  The 
author  cannot  understand  the  position  of  those  accouch- 
eurs who  will  not  shave  an  obstetric  patient,  but  do  so  for 
a simple  gynecologic  operation.  I am  convinced  that 
many  cases  of  puerperal  fever  are  due  to  the  lack  of 
surgical  preparation  of  the  patient.  A little  tact  and 
explanation  will  readily  overcome  possible  objections. 
Shaving  is  best  accomplished  with  a safety  razor  with 
the  patient  on  a table  in  the  lithotomy  position.  In 
hospitals  a shampoo  table  is  used.  The  patient  is  then 
given  a full  shower-bath.  The  body  is  well  drenched 
with  warm  water,  then,  with  a bath-brush  or  a rough 
wash-cloth  and  green  soap,  all  portions  are  briskly 
lathered.  Particular  care  is  given  the  area  between  the 
ensiform  cartilage  and  the  knees.  The  vulva  is  thor- 
oughly soaped,  and  any  smegma  removed  from  the 
clitoris . This  should  be  emphasized.  The  patient  then 
stands  under  the  shower  again,  and  all  the  lather  is 
thoroughly  removed  with  friction.  (An  ordinary  hand- 
spray  or  bath-ring  will  suffice.)  Putting  the  patient  in 


I IO 


CARE  DURING  LABOR 


a tub  is  not  so  aseptic  a procedure  as  this  one,  because 
the  particles  washed  off  the  skin  may  find  their  way  into 
the  vagina.  While  this  danger  is  not  great  in  primiparae, 
it  is  present  in  multiparae.  After  the  bath,  before  the 
patient  is  dried,  the  trunk  is  washed  with  i : 1500 
bichlorid  from  the  ensiform  to  the  knees,  making  the 
application  of  the  solution  to  the  genitals  particularly 
thorough.  Some  physicians  prefer  lysol,  1 per  cent., 
and  other  antiseptics  for  this  purpose.  While  washing 
the  genitals  the  nurse  holds  a sponge  in  the  introitus  to 
prevent  wash- water  or  other  solution  from  running  into 
the  vagina,  and  in  washing  the  anal  region  a sponge  that 
has  passed  over  the  anus  must  not  pass  over  the  vulvar 
orifice,  but  should  always  be  thrown  away.  Sterile 
underclothes  are  now  put  on.  The  hair  is  braided  in 
two  firm  braids.  The  patient  wears  a loose  house-wrap- 
per. The  confinement  room  must  be  warm  enough  so 
that  the  patient  does  not  require  heavy  clothing. 

The  patient  is  instructed  not  to  touch  the  parts , and  she 
must  not  sit  on  a water-closet  after  this  preparation. 

A sterile  slop  jar  is  provided  for  use  in  the  confinement 
room,  and  a sterile  bed-pan  for  use  on  the  confinement 
bed. 

Preparation  for  the  Doctor.  Plenty  of  water  for 
the  physician  to  wash  his  hands,  a nail-cleaner,  and 
sterile  brushes  are  provided,  and  antiseptic  solutions  are 
prepared  according  to  his  practice,  which  the  nurse  must 
inquire  about.  One  per  cent,  lysol,  1 : 1000  bichlorid, 
1 : 1000  sublamin,  and  2 per  cent,  creolin  are  commonly 
used.  (See  pages  442,  443.)  Some  accoucheurs  sterilize 
the  hands  and  lubricate  the  examining  fingers  with 
sterile  vaselin.  Other  physicians  use  sterilized  rubber 
gloves,  which  is  by  far  the  best  way.  A sterile  gown 
or  apron  is  provided  for  the  doctor  to  wear  during  the 
examination. 


CARE  DURING  THE  EIRST  STAGE 


I I I 

Both  abdominal  and  vaginal  examinations  are  usually 
made.  For  the  abdominal,  the  patient  is  brought  to  the 
side  of  the  bed  or  lies  on  a couch,  and  the  physician 
determines  the  position  of  the  child  by  palpating  the 


Figs.  52,  53. — Two  types  of  pelvimeters. 


uterus,  and  counts  the  heart-beats.  The  accoucheur 
measures  the  pelvis,  if  he  has  not  already  done  so,  using 
for  this  purpose  an  instrument  known  as  a pelvimeter 
(Figs.  52,  53).  To  prepare  the  patient  for  this  exam- 
ination a sheet  is  thrown  over  the  lower  part  of  the 


I 12 


CARE  DURING  LABOR 


body  and  just  covers  the  pubic  region ; the  night-dress  is 
drawn  up  over  the  chest  and  covered  by  a towel,  so  that 
the  abdomen  alone  is  exposed  (Fig.  54). 

After  the  external  examination  the  patient  is  prepared 
for  the  internal  examination  (Fig.  55).  The  bed  clothes 
are  neatly  folded  over  the  foot-board  of  the  bed,  the 
knees  are  drawn  up  and  separated,  a sheet  is  thrown 
with  its  center  over  the  pubis,  on  the  bias;  the  opposite 
corners  are  drawn  around  each  leg  so  as  to  cover  it;  the 
other  two  corners  are  drawn,  one  over  the  face  and  the 
other  to  form  a flap  between  the  knees.  This  is  lifted  up 


when  the  physician  is  ready  to  pass  the  hand  for  exami- 
nation. 

The  vulva  is  again  washed  by  the  nurse  with  1 : 1500 
bichlorid  or  1 per  cent,  lysol,  and  a bit  of  cotton  soaked 
in  the  solution  is  left  between  the  labia,  which  the  phys- 
ician removes  when  he  inserts  the  finger  into  the  vagina. 
While  the  examination  is  being  made  the  flap  of  the 
sheet  may  be  dropped  over  the  arm  of  the  examiner. 
After  the  examination  the  vulva  is  cleansed  again  with 
solution  and  a sterile  pad  applied.  These  aseptic  pre- 
cautions are  repeated  before  and  after  each  and  every 
examination. 


CARE  DURING  THE  FIRST  STAGE 


13 


The  Diet  in  the  First  Stage. — Most  patients  have  no 
appetite  after  labor  begins,  but  they  must  not  be  allowed 
to  starve,  since  this  causes  faintness,  which  may  delay 
8 


CARE  DURING  LABOR 


114 

the  labor.  Serious  postpartum  hemorrhage  may  result 
from  the  general  weakness.  Light  semisolid  food, 
especially  food  drinks,  must  be  urged  at  regular  intervals 
during  the  labor,  especially  if  it  is  prolonged.  During 
summer  the  drinks  from  the  soda-fountain  may  be  given. 
The  food  should  be  daintily  served,  and  with  quiet 
insistence  the  nurse  can  usually  succeed  in  getting  the 
patient  to  take  sufficient  nourishment.  Some  patients 
vomit  throughout  labor.  Some  food  must,  neverthe- 
less, be  given. 

The  History =sheet. — As  soon  as  a nurse  arrives  on  a 
case  she  should  start  a record,  and  note  the  a.  m.  and 
p.  m.  temperature,  pulse,  and  respiration,  and  other  things 
of  importance.  This  record  may  be  very  valuable  if  the 
patient  later  develops  a complication.  The  happenings 
during  labor,  the  strength  and  frequency  of  pains,  the 
frequency  of  the  child’s  heart-tones,  the  number  of 
internal  examinations  made,  the  findings,  the  local  and 
other  treatment,  the  amount  of  sleep,  the  food  taken 
— all  should  be  noted  on  the  record  with  great  care. 
Not  alone  does  this  keep  the  nurse  in  practice  and  pre- 
vent her  from  becoming  careless  and  desultory  in  her 
work,  but  it  also  has  a good  effect  on  the  physician, 
stimulating  him  to  better  effort,  and  giving  him  a high 
opinion  of  the  good  qualities  of  the  nurse  and  of  the 
nursing  profession  in  general.  Outside  of  all  this,  it  is 
of  distinct  benefit  to  the  patient,  in  that  a carefully  kept 
record  will  shed  light  on  any  complication  that  might 
arise  in  the  course  of  the  case. 

General  Instructions. — The  patient  must  be  en- 
couraged by  the  nurse  to  bear  her  pains  bravely,  but  too 
much  sympathy  is  harmful,  because  the  patient  then 
thinks  she  is  in  a serious  condition.  No  babbling  rela- 
tives or  friends  should  be  allowed  in  the  room,  and  the 
nurse  must  tell  no  stories  of  her  obstetric  exploits  or  of 


CARE  DURING  THE  FIRST  STAGE 


I 15 

harrowing  cases  had  with  physicians.  The  patient  will 
at  once  imagine  these  are  perhaps  her  fate.  The  confine- 
ment room  should  be  quiet,  cheerful,  and  hopeful.  The 
patient  should  be  left  much  alone,  so  that  the  bowels  and 


Fig.  56. — A labor  case  in  Holland  in  the  seventeenth  century  (Witkowski). 


bladder  may  be  attended  to,  and  other  services  rendered 
by  the  nurse. 

Throughout  the  whole  labor  the  nurse  should  see  that 
the  patient’s  person  is  not  unnecessarily  exposed,  but  she 
must  not  err  with  too  much  zeal,  because  at  some  periods 
of  the  labor  exposure  of  the  body  is  necessary.  For 


CARE  DURING  LABOR 


116 

many  centuries  women  were  delivered  under  a heavy 
sheet  (Fig.  56),  all  the  laws  of  asepsis  being  defied.  The 
parturient  must  also  be  protected  from  drafts,  since 
during  labor  the  skin  is  moist  and  sensitive  to  chilling. 
During  winter  the  patient  often  needs  a hot- water  bag  at 
the  feet. 

During  the  first  stage  the  patient  may  be  up  and  walk 
around,  lying  down  occasionally  on  the  sofa.  This  helps 


Fig.  57. — Physician  assisting  parturient,  and  teaching  her  how  to  use  her  powers 
to  best  advantage. 


the  pains  and  takes  her  mind  off  them.  As  the  second 
stage  approaches,  the  pains  coming  closer  together,  and 
the  patient  complaining  of  their  cutting  or  tearing 
character,  the  parturient  will  feel  safer  in  bed  on  her 
back.  She  thus  awaits  the  rupture  of  the  bag  of  waters. 
When  the  waters  break,  the  doctor  usually  makes  an 
examination  to  see  if  the  cord  has  prolapsed,  to  deter- 


WHEN  TO  SUMMON  THE  DOCTOR 


117 


mine  the  amount  of  dilatation  of  the  cervix,  and  the  posi- 
tion the  head  occupies  in  the  pelvis. 

The  patient  may  request  that  her  husband  be  present 
in  the  room.  During  the  first  stage  no  objection  may  be 
made  to  this.  During  the  second  stage  in  most  cases 
the  husband  may  be  excused  unless  he  is  needed  as  an 
assistant.  He  is  dressed  in  one  of  the  sterile  night- 
gowns and  washes  his  hands  carefully. 

If  the  first  stage  is  prolonged,  the  nurse  should  see 
that  both  the  patient  and  herself  get  some  rest.  The 
nurse  should  obtain  some  sleep,  so  that  she  will  be  able 
to  stand  the  strain  during  the  delivery  and  after.  Self- 
sacrifice  on  the  part  of  the  nurse  here  is  not  good  policy 
in  the  end. 

When  to  Summon  the  Doctor.  It  is  best  for  the 
nurse  to  obtain  exact  instructions  from  the  physician  as  to 
when  he  wishes  to  be  called.  Some  accoucheurs  allow 
the  nurse  to  take  pelvic  measurements,  to  watch  the 
fetal  heart-tones,  to  make  internal  examinations,  and 
actually  conduct  the  labor  until  the  head  is  about  ready 
for  delivery.  Others  place  less  responsibility  on  the 
nurse. 

The  physician  should  be  notified  when  labor  declares 
itself.  After  he  knows  that  everything  is  in  good  condi- 
tion he  usually  leaves  the  woman  to  the  nurse,  returning 
from  time  to  time  until  the  second  stage  begins,  then  re- 
maining until  labor  is  completed.  As  a general  rule  the 
doctor  should  be  summoned  when  the  pains  are  at  three- 
minute  intervals,  when  they  are  regular  and  very  strong, 
and  certainly  when  there  is  bulging  of  the  perineum. 
A good  way  for  the  nurse  to  determine  if  the  head  is  ad- 
vancing is  to  press  upward  alongside  the  pubis,  as  in  Fig. 
58.  At  first  a hard  resistance  is  felt  deep  in,  which 
becomes  more  marked  as  the  pains  force  the  head  down 
on  to  the  perineum.  If  the  head  can  thus  be  felt  the 


i8 


CARE  DURING  LABOR 


physician  is  to  be  summoned.  A rectal  examination 
will  also  show  the  advance  of  the  head.  The  physician 
should  be  called  earlier  to  a multipara  than  to  a primi- 
para,  because  in  the  former  the  second  stage  is  shorter. 

Of  course  the  nurse  must  notify  the  doctor  if  the  fetal 
heart- tones  grow  irregular,  or  too  slow,  or  too  fast;  if 
the  parturient  complains  of  headache  or  other  symp- 


Fig.  58. — Determining  the  rate  of  advance  of  the  head  by  pressing  in  the  peri- 
neum. 


toms  of  eclampsia,  if  there  is  hemorrhage,  or  fever,  or 
when  anything  disturbs  the  normal  course  of  labor. 
In  the  author’s  opinion  such  responsibilities  in  practice 
are  too  great  to  be  placed  on  the  nurse. 

Care  During  Second  Stage.  -When  the  patient 
arrives  in  the  second  stage,  the  bed  is  dressed  with  sterile 
sheets  unless  already  so  prepared.  The  aseptic  confine- 
ment jacket  (see  Fig.  44)  and  leggings  (see  Fig.  45)  are 


CARE  DURING  SECOND  STAGE 


1 19 


put  on,  and  extra  clothing  and  unnecessary  things  are 
removed.  This  period  is  the  stage  of  expulsion,  and  the 
patient  may  want  to  pull  on  something  as  an  aid  to  her 
bearing-down  efforts.  Unless  the  nurse  is  strong,  she 
should  not  allow  the  patient  to  pull  much  on  her  hands, 
but  should  tie  a sheet  to  a strong  post  at  the  foot  of  the 
bed  and  let  the  patient  pull  on  this.  If  the  patient,  as  is 
often  the  case,  wishes  to  hold  a human  hand,  have  the 
husband  prepare  his  hands  and  put  on  a sterile  gown. 


Fig.  59. — Nurse  curing  cramp  in  leg  during  labor. 

He  may  thus  help  in  the  labor.  The  nurse  should  save 
her  strength  as  much  as  possible,  because  obstetric  work 
is  hard. 

The  patient  may  feel  better  if  pressure  is  made  on  the 
small  of  her  back,  or  if  that  part  be  briskly  rubbed, 
which  the  nurse  may  do.  A hot- water  bag  may  also  be 
applied  to  the  base  of  the  spine.  Occasionally  washing 
the  hands  and  face  with  cold  water  is  also  grateful.  If 
the  patient  should  have  a cramp  in  her  leg,  which  not 
seldom  happens,  the  nurse  stretches  the  limb  out  forcibly 


20 


CARE  DURING  LABOR 


and  pulls  the  foot  toward  the  knee,  as  shown  in  Fig.  59. 
It  is  the  understanding  of  these  details  of  nursing  and 
caring  for  the  patient’s  comfort  that  distinguishes  the 
successful  from  the  unsuccessful  nurse. 

Some  patients  are  unruly,  and  persist,  against  advice, 
in  putting  the  hands  on  the  sterile  abdominal  towel  or 
even  on  the  vulva.  In  such  a case  the  nurse  should  ster- 
ilize the  parturient’s  hands  with  1 : 1000  bichlorid  or 
tie  them  loosely  at  the  head  of  the  bed. 


Fig.  60. — Sewing  table  arranged  near  bed  during  second  stage.  Carries  basin 
of  1 per  cent,  lysol  and  i:  1500  bichlorid  (or  other  solutions  as  ordered),  with 
sponges,  pitcher  of  hot  sterile  water,  pile  of  sterile  towels,  saucer  with  sterile 
tape,  scissors,  and  artery  forceps. 

When  the  pains  are  strong  and  frequent  the  physician 
usually  gives  the  patient  an  anesthetic  to  the  obstetric 
degree — that  is,  to  partial  anesthesia. 

Scopolamin  and  morphin,  pantopon,  chloral,  and  other 
drugs  are  used  to  alleviate  the  suffering  of  the  first  stage. 
If  the  nurse  is  not  familiar  with  the  physiologic  action 
of  these  remedies  she  should  ask  the  physician  what  effect 
she  should  look  for.  In  the  second  stage  ether  and 
chloroform  are  given.  Ether  is  preferred  by  the 
author,  as  it  damages  the  liver  less. 


CARE  DURING  SECOND  STAGE 


121 


The  nurse  now  surveys  the  room  to  see  if  everything 
is  in  readiness  for  the  delivery.  She  should  see  to  it  that 
the  following  things  are  ready:  A basin  of  hand  solution 
for  the  physician ; a basin  of  pledgets  soaking  in  an  anti- 
septic solution  (what  these  solutions  are  the  doctor  tells 
the  nurse) ; tape  for  tying  the  cord,  and  scissors  for  cut- 
ting same,  in  a glass  or  saucer  with  a little  i per  cent, 
lysol  solution  over  them;  warm  saturated  boric  acid 
solution  for  washing  the  eyes,  and  some  gauze  pledgets 
to  open  the  lids  with;  nitrate  of  silver  solution,  i per 
cent.,  and  salt  solution  or  whatever  drug  the  doctor  pre- 
fers for  preventing  ophthalmia  neonatorum.  A steril- 
ized douche-pan  is  in  readiness,  and  the  sterile  douche- 
bag  is  gotten  ready  so  that  it  can  be  filled  with  hot  i per 
cent,  lysol  solution,  and  hung  up  near  the  bed  for  use 
in  an  emergency  (postpartum  hemorrhage)  with  a mini- 
mum of  delay. 

The  nurse  should  have  a good  reserve  of  sterile 
pledgets,  towels,  sheets,  hot  and  cold  water,  and  she 
should  know  just  where  to  put  her  hand  on  them  when 
needed. 

The  baby’s  basket  contains  a warm  receiver,  a hot- 
water  bag,  and  a warm  wool  blanket.  The  nurse  should 
have  a baby  bath-tub  nearby,  with  bath  thermometer 
and  plenty  of  hot  water  in  case  the  child  is  asphyxiated 
when  it  comes  and  the  accoucheur  calls  for  a hot  bath. 

One  of  the  sterile  obstetric  pads  is  put  under  the 
patient  and  the  body  is  covered  by  a sterile  sheet. 
If  the  patient  is  dressed  with  sterile  leggings  and  jacket, 
all  that  is  needed  is  to  lay  a sterile  towel  over  the  abdo- 
men, letting  one  end  drop  between  the  thighs.  For 
delivery  on  the  back  the  woman  lies  as  in  Fig.  62,  but 
if  the  physician  prefers  delivery  on  the  side,  the  hips  are 
brought  to  the  side  of  the  bed,  and  the  pillow  before 
described  is  placed  between  the  knees  (Fig.  61).  The 


122 


CARE  DURING  LABOR 


patient  is  now  protected  from  infection  and  exposure  by 
a sterile  sheet  and  towels. 

During  delivery  the  nurse’s  duties  will  consist  of  wait- 
ing on  the  doctor;  renewing  supplies  of  pledgets  and 
solutions;  adjusting  the  towels,  pillow,  sheet,  etc.,  and 
little  attentions  about  the  patient,  one  of  which  is  caring 
for  any  discharge  from  the  rectum.  If  the  enema  has 


Fig.  61. — Arrangement  for  delivery  on  side  in  a home.  Hot  and  cold  sterile 
water  in  pitchers.  One  basin  has  bichlorid,  1 11500;  another,  i \ per  cent,  lysol  so- 
lution. Scissors,  cord  tape,  artery  clamp,  and  catheter  lie  in  a saucer  in  1 per 
cent,  lysol  solution.  A pile  of  sterile  towels  and  the  nurse’s  hand  forceps  are 
on  the  table.  At  the  extreme  left  is  the  warm  receiver  for  the  infant. 


not  completely  emptied  the  lower  bowel,  as  the  head 
comes  down  the  contents  of  the  bowel  are  forced  out 
and  cause  considerable  annoyance  to  the  accoucheur  on 
account  of  the  danger  of  infection  from  the  feces  getting 
into  the  vagina.  Women  have  died  from  this.  Aside 
from  the  danger  of  infection,  the  patient  is  much  dis- 
tressed about  it;  therefore  the  nurse  should  never  allow 
her  to  learn  that  such  an  occurrence  has  taken  place. 
The  discharges  from  the  anus  are  received  in  large 


CARE  DURING  SECOND  STAGE 


123 


pledgets  of  cotton  soaked  in  1 : 1500  bichlorid,  taking 
care  that  nothing  touches  the  vulva,  and  the  perineum 
must  be  sponged  with  the  same  solution,  always  rubbing 
from  the  vulva  toward  the  anus,  and  not  using  the  same 
pledget  twice.  Should  the  physician  soil  his  hand,  he 
will  resterilize  it,  after  which  the  nurse  replenishes  the 
antiseptic  solution. 


Fig.  62. — Patient  arranged  for  the  conduct  of  the  third  stage  of  labor. 


When  the  child  is  coming  through  the  vulva,  the 
nurse  may  have  to  administer  the  anesthetic,  which  is 
done  as  follows:  The  bottle  is  arranged  for  dropping  by 
cutting  a long  slit  in  the  side  of  the  cork.  An  ether 
can  may  be  provided  with  an  excellent  dropper  as  in 
Fig.  63.  A handkerchief  or  an  inhaler  may  be  used. 
Just  as  the  pain  comes  on  15  drops  of  the  drug  are 


24 


CARE  DURING  LABOR 


dropped  on  the  handkerchief;  after  a few  moments  a 
little  more  is  put  on,  and  as  the  height  of  the  pain  passes 
the  mask  is  removed  from  the  face.  Toward  the  end  of 
delivery  the  administration  is  more  continuous,  but 
ceases  immediately  the  head  is  born.  The  nurse  watches 
the  doctor  for  instructions  as  to  whether  he  wishes  more 
or  less  of  the  anesthetic  given.  When  ether  is  used 
one  should  not  be  too  near  an  open  flame,  since  the 


Fig.  63. — Ether  can  with  safety-pin  as  dropper. 


vapor  is  explosive.  Chloroform  is  decomposed  by  an 
open  flame  into  irritating  and  poisonous  vapors. 

As  soon  as  the  head  is  born  the  nurse  must  have 
ready  warm  boric  solution  for  the  eyes  and  gauze  pled- 
gets for  wiping  out  the  nose,  mouth,  and  throat.  Soft  old 
linen  or  lintine  is  the  best  for  this  purpose.  When  the 
baby  comes,  it  is  received  in  a warm  towel,  and  allowed 
to  lie  a short  distance  from  the  mother,  the  nurse  taking 
care  that  it  should  not  pull  on  the  cord,  and  that  the 
mother  does  not  lie  on  it  or  squeeze  its  head  between 


CARE  DURING  THE  THIRD  STAGE 


25 


her  legs  (see  Fig.  62).  The  child  must  not  be  exposed, 
because  it  is  very  subject  to  chilling,  being  so  wet. 

In  maternities  the  infant  should  now  be  marked,  to 
avoid  every  chance  of  confusion  in  the  nursery.  Its 
name,  written  on  a square  of  adhesive,  is  placed  on  its 
back,  or  a distinguishing  number  tied  on  its  wrist. 

A basin  or  bed-pan  is  placed  under  the  vulva.  Now 
the  doctor  calls  for  the  bowl  with  tape  for  cord  and 
scissors,  and  ties  and  cuts  the  cord.  After  the  baby  is 
separated  from  its  mother  it  is  wrapped  in  a warm  re- 
ceiver and  placed  in  the  warm  basket,  on  its  side,  with 
the  head  lower  than  the  body,  so  that  mucus  can  run 
out  of  the  throat  and  mouth.  It  is  immaterial  which 
side  the  child  lies  on. 

The  nurse  must  watch  the  infant  closely  to  see  that  it 
does  not  choke  and  that  it  does  not  kick  all  the  covers 
off;  that  it  is  not  near  a window  or  in  a draft,  and  that 
the  cord  does  not  bleed.  The  nurse  may  have  to  delegate 
some  of  these  duties  to  the  father  or  some  relative  if  her 
services  are  required  by  the  patient  or  by  the  doctor. 

Care  During  the  Third  Stage. — As  the  child  leaves 
the  vagina  the  nurse  or  doctor  should  follow  down  the 
receding  uterus  with  the  hand  placed  on  the  abdomen — 
this  to  prevent  hemorrhage  (Fig.  64).  Since  some  phys- 
icians do  not  practice  this,  the  nurse  should  obtain  in- 
structions. When  the  child  is  delivered  the  uterus  is 
the  size  of  a cocoanut,  and  the  nurse  grasps  it  in  the  full 
hand  and  notes  whether  it  is  hard  or  soft.  If  too  soft, 
she  gives  it  a gentle  massage  until  it  hardens,  and,  as  a 
rule,  there  is  no  trouble.  If  the  nurse  is  uncertain  as  to 
its  condition,  let  her  not  hesitate  to  ask  the  physician 
about  it.  As  soon  as  the  cord  is  tied  the  doctor  usually 
takes  the  uterus,  and  the  nurse  is  now  free  to  rearrange 
and  refill  basins,  see  a little  to  the  baby,  and  to  get  things 
ready  for  the  placenta. 


26 


CARE  DURING  LABOR 


After  the  child  is  removed  the  nurse  takes  away,  if 
necessary,  gently  and  without  jarring  the  patient,  all  the 


soiled  towels,  etc.,  from  about  her,  and  puts  a folded,  dry, 
warm  sheet  under  her,  or  the  other  sterile  obstetric  pad. 
A sterilized  basin  or  bed-pan  is  again  slipped  snugly 


Fig.  64. — iN'urse  holding  the  uterus  during  third  staj 


CARE  DURING  THE  THIRD  STAGE 


27 


under  the  vulva  to  catch  all  discharges.  This  prevents 
soiling  the  bed  and  gives  the  accoucheur  an  idea  of  the 
quantity  of  blood  the  patient  is  loosing.  The  nurse  ob- 
serves and  notes  the  amount  of  blood  in  the  clothes,  so 
as  to  form  some  estimate  of  the  total  amount  lost.  The 
patient  is  then  arranged  and  made  comfortable  and 
covered  with  a clean  blanket,  which  is  protected  by  a 
sheet  from  being  soiled. 

If  the  nurse  is  to  guard  the  uterus  (see  Fig.  64),  she 
must  observe  the  following  points: 

1.  That  the  uterus  is  hard,  and  that  when  it  relaxes  a 
little,  as  it  should,  it  does  not  balloon  out  with  blood. 

2.  She  must  look  between  the  thighs  every  three 
minutes  to  see  if  blood  is  accumulating  in  the  basin  or 
on  the  clean  sheet  she  has  placed  there. 

3.  She  must  keep  her  finger  on  the  patient’s  pulse  and 
her  eye  on  the  patient’s  face,  to  detect  unusual  rapidity 
of  one  and  paleness  of  the  other. 

If  there  is  a hemorrhage,  the  nurse  must  firmly  but 
gently  massage  the  uterus.  The  thumb  lies  in  front,  the 
fingers  on  the  back,  of  the  uterus,  and  together  they  de- 
scribe circles  on  the  organ,  wiping  the  abdominal  wall 
over  the  uterus — not  kneading  the  abdominal  wall,  but 
the  uterus.  Of  course,  the  physician  is  informed  of  it. 

The  nurse  will  notice  when  the  after-pains  come  on  that 
the  uterus  gets  very  hard  and  rises  up  under  the  hand. 
These  contractions  of  the  uterus  loosen  and  expel  the 
placenta.  The  contractions  of  the  uterine  muscle  also 
prevent  postpartum  hemorrhage.  During  the  active 
uterine  contraction  the  hand  may  be  removed  from  the 
fundus.  The  separation  of  the  placenta  is  shown  by  the 
uterus  rising  up  in  the  abdomen,  up  above  the  navel,  and 
the  cord  advancing  from  the  vulva.  It  is  usually  time 
now  to  expel  the  placenta,  though  many  physicians 
arbitrarily  wait  thirty  minutes. 


128 


CARE  DURING  LABOR 


When  the  physician  is  ready  to  do  this,  the  nurse 
presses  the  sterile  basin  against  the  perineum,  the  cord  is 
dropped  into  it,  and  the  after-birth  is  gently  expelled 
from  the  vulva,  from  which  it  drops  slowly  into  the 
basin.  The  membranes  are  carefully  pulled  from  the 
uterus  by  gentle,  steady  traction,  so  that  they  do  not  tear 
off.  The  physician  will  inspect  the  placenta  and  mem- 
branes carefully  to  see  if  no  piece  of  either  is  left  in 
the  uterus— a serious  danger — therefore  the  nurse  will 
place  the  basin  containing  them  where  he  may  see  them 
before  he  leaves  the  house.  It  would  not  be  improper 
for  the  nurse  to  call  the  physician’s  attention  to  this 
point  if  he  should  forget  it,  and  the  information  obtained 
might  later  be  of  signal  service. 

After  the  placenta  and  membranes  are  removed  the 
physician  inspects  the  vagina  and  vulva  to  discover  the 
presence  and  extent  of  the  lacerations  of  the  birth-canal. 
If  none  are  found,  soiled  towels  are  taken  away  and  a 
clean  sheet  spread  under  the  patient.  The  hand  guards 
the  uterus,  noting  the  same  points  as  before.  The 
physician  usually  does  this,  but  the  nurse  may  have  to 
do  it.  A short  period  of  rest  is  given  the  woman,  then 
the  blood-stains  are  washed  off,  using  cool  sterile  water 
unless  the  room  be  cold,  when  warm  water  should  be 
used.  Great  care  should  be  taken  not  to  rub,  hurt,  or 
infect  the  vulva.  A sterile  pad  is  placed  against  it  to 
catch  the  discharges.  The  bed  is  now  dressed. 

During  these  manipulations  the  patient  must  not  be 
roughly  tossed  about.  Whenever  the  parturient  is 
turned  or  lifted,  one  hand  must  be  on  the  uterus,  seeing 
that  it  is  hard,  and  the  legs  must  be  tightly  closed  to- 
gether. This  precaution  is  to  prevent  air  from  being 
drawn  into  the  vagina  and  thence  into  the  large  veins  of 
the  uterus,  thus  causing  air-embolism,  which  is  usually 
fatal;  this  is  an  important  warning.  The  confinement 


PERINEORRHAPHY 


I29 

jacket  is  removed,  and  a clean  plain  night-gown  is  put 
on.  The  abdominal  binder  is  now  applied.  This  is 
broad,  going  from  the  ensiform  to  the  hips,  and  is 
pinned  from  above  downward.  No  pads  are  needed 
under  it. 

PERINEORRHAPHY 

If  a perineorrhaphy  must  be  done,  or,  as  the  woman 
may  express  it,  if  it  is  necessary  to  “put  in  stitches,”  the 
plan  of  procedure  must  be  altered.  While  waiting  for 
the  placenta  the  nurse  prepares  for  the  operation.  The 
necessary  instruments  are: 

Three  pairs  scissors. 

Three  tissue  forceps. 

Four  short  artery  forceps,  two  8-inch  forceps. 

Two  needle-holders. 

Six  curved  needles. 

Three  vaginal  retractors,  two  large  and  one  small. 

Two  vulsellum  forceps  and  two  cervix  forceps. 

Long  uterine  packing  forceps. 

Catheter,  and,  if  a douche  is  to  be  given,  a uterine 
douche  point. 

Suture  material  is  usually  catgut  and  silkworm  gut, 
which  may  be  boiled  with  the  instruments  unless  already 
sterilized. 

The  nurse  refills  the  basins  with  hot  solutions,  sees 
that  there  is  a good  supply  of  pledgets,  preferably  gauze, 
or  covered  sponges,  and  that  the  light  is  good.  Things 
are  arranged  as  in  Fig.  87. 

After  the  placenta  is  out,  the  patient  is  slowly  moved 
across  the  bed,  or — and  the  writer  heartily  recom- 
mends this — she  is  put  on  a table,  and  the  basins,  in- 
struments, etc.,  arranged  as  for  a major  operation.  Too 
many  women  date  lifelong  invalidism  to  the  neglect  of 
proper  repair  of  injuries  of  the  pelvic  floor,  and  one 
9 


CARE  DURING  LABOR 


I30 


should  not  spare  any  effort  to  secure  primary  union  of 
such  lacerations.  It  goes  without  saying,  that  better 


results  may  be  obtained  when  the  accoucheur  has  his 
work  comfortably  arranged  than  when  he  must  operate 


FERINE  ORRHA  PH  Y 


131 

over  a low  bed  in  a strained  attitude,  where  it  is  difficult 
to  carry  out  the  demands  of  an  aseptic  technic. 

In  the  absence  of  sufficient  trained  assistance  the 
husband  or  a courageous  woman  may  be  asked  to  hold 
the  patient’s  legs;  or  the  sheet-sling  (see  Fig.  90) 
may  be  used.  An  anesthetic  is  often  not  necessary, 
most  women  being  able  to  stand  the  pain,  and  further, 
the  parts  are  not  so  sensitive  at  this  time,  as  they  have 
been  benumbed  by  the  stretching  caused  by  the  child. 
When  the  operation  is  completed,  the  nurse  should  ask 
the  physician  to  catheterize  the  patient,  and  at  the 
same  time  show  her  where  the  urethral  orifice  is,  as  some- 
times the  bruising  and  tearing  caused  by  the  delivery 
make  it  so  swollen  that  she  is  unable  to  recognize  it  by 
the  usual  landmarks. 

Lacerations  of  the  perineum  are  of  three  degrees: 
first,  through  the  fourchet;  second,  to  but  not  through 
the  sphincter  of  the  anus;  and  the  third  degree,  through 
the  anus  into  the  rectum.  The  last  form  is  a very  seri- 
ous accident,  as  the  patient  loses  control  of  the  bowel 
unless  repair  can  be  successfully  made. 

There  is  a popular  notion  that  when  a woman  acquires 
a laceration  of  the  perineum  during  labor,  it  is  the  phys- 
ician’s fault.  While  it  is  true  that  by  a proper  conduct 
of  labor  most  lacerations  and  nearly  all  serious  ones  can 
be  avoided,  still  it  is  also  true  that  sometimes  the  peri- 
neum will  tear  like  wet  blotting-paper,  and  no  skill  can 
save  it.  In  communities  where  the  above  notion  is 
prevalent  the  physician  is  often  tempted  to  neglect  the 
repair  of  lacerations  of  the  perineum,  as  he  will  acquire 
a reputation  of  “ tearing  his  women.”  His  neighbor 
does  not  have  lacerations  because  he  does  not  put  in  so 
many  “ stitches.”  The  nurse  may  do  much  to  assist 
the  conscientious  physician  by  explaining  to  the  family 
the  frequency  of  injuries  to  the  pelvic  floor  and  the 


32 


CARE  DURING  LABOR 


necessity  for  their  repair.  Good  obstetrics  is  thus 
furthered. 

When  the  mother  is  in  bed  and  made  comfortable, 
the  room  is  aired  and  darkened  a little,  and  ordered 
neatly,  so  that  the  patient  may  obtain  some  well-earned 
rest.  Temperature,  pulse,  and  respiration  are  taken  and 
recorded,  and  a warm  drink  is  given.  After  this  the 
soiled  towels,  sheets,  etc.,  are  gathered  together  and 
put  to  soak  in  cold  water.  The  linen  soiled  with  fecal 
matter  should  be  soaked  separately,  and  those  articles 
that  are  very  bloody  should  be  rinsed  out  before  being 
put  with  the  rest.  After  soaking  in  several  changes  of 
cold  water  and  thorough  rinsing,  they  may  be  sent  to 
the  laundry.  Hot  water  should  not  be  used  on  bloody 
clothes,  as  the  heat  coagulates  the  blood  in  the  mesh  and 
thus  permanent  stains  are  left.  Towels  wet  with  bi- 
chlorid  should  also  be  well  rinsed  before  being  boiled, 
as  the  mercury  stains  cannot  be  removed.  Cotton 
sponges  and  the  placenta  must  not  be  thrown  into  the 
water-closet.  They  clog  the  pipes. 

THE  FIRST  CARE  OF  THE  NEWBORN  CHILD 

The  nurse  assures  herself  that  the  mother  is  in  good 
condition,  that  the  uterus  is  firm,  and  that  there  is  no 
hemorrhage  from  the  vulva.  She  then  takes  the  infant, 
after  arranging  all  her  material  for  oiling  and  dressing 
it,  near  the  radiator  or  fire,  away  from  a strong  light 
or  draft.  The  eyes  are  attended  to  usually  by  the 
physician.  He  has  simply  washed  the  lids  outside  and 
inside  with  boric  solution,  or  he  has  used  Crede’s  or  some 
similar  treatment.  For  Crede’s  method  or  the  nitrate  of 
silver  method  the  nurse  prepares  a weak  solution  of  com- 
mon salt,  and  has  a i or  2 per  cent,  nitrate  of  silver  solu- 
tion at  hand.  The  lids  are  gently  separated,  and  1 drop 
of  the  silver  solution  put  in  each  eye.  It  is  then  neutral- 


THE  FIRST  CARE  OF  THE  NEWBORN  CHILD  1 33 


ized  with  the  saline  solution.  Unless  the  silver  solution 
is  made  fresh  every  day  or  so,  severe  “nitrate  reactions” 
of  the  conjunctiva  may  result.  Lately,  10  per  cent, 
solution  of  protargol,  or  25  per  cent,  argyrol,  is  being 
used  for  the  prevention  of  ophthalmia  neonatorum. 

The  infant  is  oiled  all  over  with  warm  olive  oil,  albo- 
lene,  or  benzoated  lard,  great  care  being  taken  that  the 
hand  does  not  rub  anything  into  the  eyes.  The  vernix 
caseosa  is  thus  softened  and  dissolved.  Use  the  oil 
freely,  especially  in  the  groins  and  armpits,  where  the 
vernix  gathers,  and  wipe  the  child  dry  with  a warmed  soft 
towel.  Do  this  quickly,  and  keep  the  infant  covered  as 
much  as  possible.  The  child  may  be  held  on  the  lap  or 
placed  on  a pillow  on  a table.  The  room  should  be  warm. 

After  this  the  hands  are  sterilized  and  the  umbilical 
cord  stump  is  dressed.  First  the  stump  and  adjacent  skin 
are  washed  thoroughly  with  1 per  cent,  lysol  solution  or 
pure  alcohol,  then  wrapped  in  dry,  sterile  gauze;  then 
the  sterile  binder  is  applied.  The  baby’s  temperature 
is  now  taken,  after  which  the  child  is  quickly  dressed 
and  put  in  a warm  crib  on  either  side,  with  the  head  low. 

The  infant,  especially  if  it  is  premature  or  if  it  was 
delivered  by  a hard  operation  and  was  more  or  less 
asphyxiated,  must  be  watched  carefully  until  it  is  known 
to  have  a good  hold  on  life.  Sometimes  such  infants  are 
found  dead  in  their  cribs,  and  often  they  secrete  large 
amounts  of  mucus,  which  chokes  them.  This  mucus  may 
be  sucked  into  the  lungs  and  cause  atelectasis  (incom- 
plete unfolding  of  the  lungs),  pneumonia,  and  sepsis. 

The  child’s  color  should  be  pink  or  red,  its  cry  should 
be  vigorous,  and  if  it  sleeps,  it  should  be  calm,  and  not 
grunt  or  whine  with  each  expiration.  If  there  is  a rat- 
tling in  the  throat,  the  nurse  should  wipe  the  mucus  out 
with  the  little  finger  covered  with  a soft  cloth — gently, 
so  as  not  to  scratch  the  mouth.  The  infant  may  be  sus- 


134 


CARE  DURING  LABOR 


pended  by  the  feet  for  a few  minutes  to  allow  the  mucus 
to  run  out,  and  when  replaced  in  the  crib  should  be  put 
on  the  side  with  the  head  lower  than  the  chest  and  sup- 
ported by  a small  pillow.  Sometimes  a sip  of  water  given 
to  the  child  carries  the  mucus  down  with  it.  The  infant 
usually  needs  a hot-water  bag,  even  in  summer.  It 
should  not  be  needful  to  admonish  the  nurse  that  the 
bag  be  water-tight  and  not  hot  enough  to  burn. 

CARE  AFTER  THE  THIRD  STAGE 

While  the  nurse  is  attending  to  the  infant  she  should 
look  after  the  mother  a little  also,  noting  her  color,  rest- 
fulness, the  rapidity  and  strength  of  the  pulse,  the  firm- 
ness of  the  uterus,  and  the  amount  of  bloody  discharge. 
She  must  early  detect  a hemorrhage  if  one  occurs,  and 
determine  if  the  patient  is  in  good  condition  and  not 
shocked,  which  is  done  by  observing  the  above  symptoms. 

The  normal  flow  of  blood  from  the  genitals  in  the  first 
two  hours  after  delivery  will  not  exceed  2 ounces,  and 
there  will  be  no  clots.  If  there  is  more  discharge,  the 
nurse  should  massage  the  uterus  and  give  1 dram  of 
ergot.  The  puerpera  should  lie  on  the  back  for  three 
hours  after  delivery,  after  which  she  may  be  turned  on 
her  side,  supported  by  a pillow  at  the  back.  If  the 
uterus  has  been  packed  with  gauze,  the  nurse  is  to  sup- 
port the  abdomen  carefully  while  moving  the  woman, 
since  brusque  motion  may  tear  the  uterine  muscle  over 
the  packing. 

Headache  is  a very  important  symptom  during  and 
after  labor.  It  should  always  be  reported  to  the  phys- 
ician. An  examination  of  the  urine  for  albumin,  and  of 
the  patient  for  other  signs  of  impending  eclampsia  will 
be  made. 

One  of  the  duties  of  the  attendant  at  this  time  is  the 
filling  out  of  a birth  certificate. 

\; 


CHATTER  II 


CARE  DURING  THE  PUERPERIUM 

First,  last,  and  all  the  time  during  the  puerperium  the 
nurse  must  consistently  practice  asepsis  in  everything 
that  concerns  the  genitals  and  the  breasts  in  the  mother, 
and  the  eyes,  nose,  mouth,  and  navel  in  the  child.  The 
nurse  must  remember  that  while  she  is  only  in  small  part 
responsible  for  the  asepsis  of  the  labor,  the  major  part 
being  assumed  by  the  physician,  she  is  in  large  part 
responsible  for  the  asepsis  of  the  puerperium  of  both 
mother  and  baby.  She  dare  not  relax  her  vigilance  at 
any  period  of  her  attendance  on  the  case. 

DAILY  CARE  OF  THE  MOTHER 

The  Breasts. — After  the  mother  has  slept,  usually 
about  eight  hours,  the  nurse  prepares  the  breasts. 
They  are  gently  washed  with  soap  and  water,  then  with 
bichlorid,  i : 1500,  which  is  allowed  to  dry  in.  A loose 
breast-binder  is  now  applied,  simply  to  prevent  the  gland 
from  sagging.  Tertullian  tells  us  that  the  Roman  women 
used  a breast-binder  made  in  the  temples  and  possessing 
mystic  powers. 

A short  time  after  this  the  baby  is  applied  to  the 
nipple  (Fig.  66).  Before  and  after  each  nursing  the 
nipple  is  washed  with  saturated  boric  solution,  poured 
fresh  from  a bottle,  not  kept  in  a glass,  and  using  steril- 
ized cotton  pledgets  on  tooth-picks — so-called  “applica- 
tors” (Fig.  68).  No  further  treatment  is  required  unless 
the  nipple  is  tender,  when  it  may  be  anointed  with  sterile 

135 


CARE  DURING  THE  PUERPERIUM 


136 


albolene  or  cocoa-butter.  The  fingers  do  not  come  in 
contact  with  the  nipple  at  all;  if  it  is  necessary  to  do 


this,  the  hands  must  be  disinfected.  The  baby  is  put 
to  the  breast  every  four  hours  until  the  milk  comes, 


Fig.  66. — Woman  in  proper  position  for  nursing  an  infant. 


DAILY  CADE  OF  THE  MOTHER 


137 


Fig.  67. — The  mammillaris.  (From  a painting  in  Pompeii — Witkowski.) 


Fig.  68. — The  breast  tray  and  its  contents. 


then  every  three  hours  during  the  day  and  every  four 
hours  during  the  night.  The  first  nursing  is  at  7 A.  m., 
the  last  at  10  p.  m.,  and  the  child  is  put  to  the  breast 


38 


CARE  DURING  THE  PUERPERIUM 


once  in  the  interval  to  7 a.  m.,  at  about  2 a.  m.  Later 
in  the  puerperium  the  child  is  allowed  to  sleep  as  long 
as  it  will,  and  finally  it  is  habituated  to  sleep  all  night 
through.  Some  physicians  prefer  the  four-hour  interval 
for  robust  children. 

When  the  milk  “comes  in,”  which  usually  occurs  on 
the  third  day,  the  breasts  need  more  support  from  the 
breast-binder.  The  treatment  of  cracks,  engorgement, 
and  other  conditions  of  the  breast  will  be  taken  up  in 
the  chapter  on  Complications.  Too  much  care  and  too 
careful  asepsis  cannot  be  given  the  breasts,  as  infection, 
with  resulting  abscess  and  impaired  nipples,  with  re- 
sulting necessary  weaning  of  the  child,  must  be  avoided. 

Care  of  the  Genitals.  — Every  four  hours,  and  after 
each  bowel  movement  and  urination,  the  vulva  is  dressed. 
The  patient  is  put  on  a douche-pan,  the  nurse  provides 
everything  she  will  need  close  at  hand,  and  arranges  the 
patient  and  coverings.  Then  she  sterilizes  her  hands, 
or  uses  sterile  rubber  gloves,  gently  separates  the  labia, 
and  pours,  from  a narrow-lipped  pitcher,  a solution  of 
lysol,  1 per  cent.,  or  bichlorid,  1 : 2000,  over  the  parts. 
A little  of  the  solution  may  run  into  the  vagina.  After 
this  she  dries  the  vulva  with  gentle  pressure  by  means  of 
cotton  pledgets,  puts  on  a sterile  pad,  and  adjusts  it 
with  a T-bandage,  or  pins  the  ends  of  the  pad  to  the 
abdominal  binder.  This  dressing  must  not  be  too 
tight,  and  the  binder  must  not  be  soiled  or  wrinkled. 
A few  physicians  desire  the  patient  tightly  bound  up  in 
a long  binder  reaching  nearly  to  the  knees.  Fig.  69 
shows  such  a binder  applied.  When  a dressing  is  to  be 
made,  the  nurse  removes  the  pins  at  the  sides  and  slides 
the  binder  up  over  the  hips. 

After  the  first  day  these  attentions  are  not  needed  so 
often — only  every  six  hours — unless  there  is  much 
lochial  discharge. 


Fig.  69— The  long  binder  applied.  (From  a photograph  taken  at  the  Chicago  Lying-in  Hospital.) 


DAILY  CADE  OF  THE  MOTHER 


139 


140 


CARE  DURING  THE  PUERPERIUM 


If  there  are  stitches  in  the  perineum,  the  nurse  must 
redouble  her  carefulness  and  not  pull  on  the  ends  or 
knots  in  any  of  the  manipulations,  as  in  passing  the 
bed-pan  under  the  patient,  removing  the  pads,  etc. 
The  physician’s  best  work  may  thus  be  spoiled.  If  the 
patient  complains  of  the  stitches  hurting  her,  the  nurse 
should  inspect  the  wound  to  see  if  they  are  cutting 
through,  in  which  case  she  should  notify  the  doctor. 
Sometimes  there  is  marked  swelling  of  the  vulva  on  the 
second  day.  The  doctor  may  order  warm,  moist,  medi- 
cated applications  to  the  parts.  If  left  to  her  own  de- 
vices, the  nurse  may  apply  a warm  boric  solution  dress- 
ing to  relieve  the  swelling  and  pain.  It  is  not  necessary 
to  bind  the  knees  together  after  perineorrhaphy  unless 
the  physician  so  orders. 

Often  after  several  days  a whitish  substance  forms  in 
the  creases  of  the  vulva.  This  is  composed  of  epithelial 
scales  and  dried  and  coagulated  secretions.  It  may 
be  removed  by  anointing  the  parts  freely  with  sterile 
albolene.  After  an  hour  the  softened  and  dissolved 
material  may  be  gently  rubbed  off.  The  parts  about 
the  vulva  need  an  occasional  washing  with  soap  and 
water. 

The  hands  must  never  be  soiled  with  lochial  dis- 
charges. This  is  an  important  injunction,  because 
these  discharges  are  infectious,  and  they  may  infect  the 
puerpera  in  the  next  bed,  the  mother’s  breasts,  or  the 
umbilicus  or  the  eyes  of  the  infant,  and  also  the  finger 
of  the  nurse. 

Special  Care  in  Cases  of  Complete  laceration 
of  the  Perineum. — In  cases  where  the  sphincter  ani 
has  been  torn  and  sutured  the  nurse  will  ask  the  phys- 
ician for  special  instructions  regarding  the  diet,  and  the 
attention  to  the  bowels,  i.  e.,  cathartics  and  enemata. 
Often  liquid  diet  will  be  ordered  for  four  or  five  days 


DIET 


14 


and  food  free  from  seeds  and  woody  fiber.  Some 
physicians  give  opium  to  bind  up  the  bowels. 

Eight  hours  before  the  bowels  are  to  move  for  the 
first  time  the  nurse  will  inject  6 ounces  of  sterilized 
olive  oil  into  the  rectum.  This  softens  the  fecal  mass 
and  lubricates  the  passage.  Just  before  the  bowels  are 
to  move  an  enema  of  6 ounces  of  warm  salt  solution  is 
given.  Under  no  circumstances  should  the  patient 
be  allowed  to  strain  during  the  evacuation.  The  tend- 
ency to  strain  is  due  to  the  presence  of  a hard  mass  of 
feces  in  the  rectum.  If  the  nurse  detects  such  a tendency 
she  should  pass  the  index-finger,  gloved,  into  the  rec- 
tum, and  gently  soften  and  break  up  the  mass  by 
pressing  it  against  the  sacrum.  No  pressure  may  be 
made  on  the  line  of  sutures.  A saline  enema  (6  ounces) 
is  now  given  and  the  patient  instructed  to  retain  it  as 
long  as  possible.  Subsequent  evacuations  are  aided  in 
the  same  manner. 

The  History-sheet.  -Every  morning,  after  bowels 
and  bladder  are  empty,  the  nurse  measures  the  height 
of  the  fundus  of  the  uterus  from  the  pubis  and  notes  it 
on  her  history-sheet  as  follows:  Fundus  6 x,  meaning 
six  fingers’  breadth  from  the  pubis.  She  also  notes  the 
character  and  amount  of  the  lochia,  as  described  on  page 
63,  and  must  not  forget  to  note  and  call  the  doctor’  at- 
tention to  clots,  membranes,  etc.,  expelled,  and  to  all 
unusual  occurrences.  If  everything  progresses  smoothly, 
the  nurse’s  notes  on  her  record  may  be  a little  neglected 
by  the  attending  accoucheur,  but  if  a complication 
should  arise,  he  will  be  grateful  indeed  for  all  the  infor- 
mation he  will  find  there.  Therefore  let  the  history- sheet 
always  be  neatly  and  accurately  kept  until  the  case  is 
discharged. 

Diet. — There  was  an  old  notion  that  a woman  after 
labor  must  be  kept  on  a milk-and-water  diet,  in  the  fear 


142 


CARE  DURING  THE  TVER  PER  I UM 


that  errors  in  eating  would  cause  puerperal  fever  and 
other  diseases. 

This  notion  has  some  basis,  although  nowadays  we 
give  the  puerpera  a much  more  liberal  dietary.  If  a 
healthy  person  is  put  to  bed,  one  must  restrict  his  diet 
or  he  will  become  ill,  and  the  same  is  true  of  a puerpera. 
Lack  of  exercise  causes  the  organs  to  work  less,  and  a 
quiet  body  needs  less  food.  If  food  is  given  in  large 
quantities,  it  is  not  properly  oxidized  or  assimilated  and 
“clogs  the  system”  with  waste  matters.  The  excretory 
organs  are  thus  given  more  work  to  do,  and  they  are  not 
in  fit  condition  because  of  the  lack  of  exercise. 

Headache,  lassitude,  an  odor  to  the  skin,  tympany, 
high-colored  urine,  even  graver  troubles,  may  be  the 
evidences  of  overfeeding. 

During  the  first  eighteen  hours  after  the  labor  the 
patient  should  have  liquids  in  amounts  sufficient  to 
quench  her  thirst.  After  a few  hours  a cup  of  broth 
or  tea  and  a small  slice  of  buttered  toast,  a glass  of  milk, 
plain  or  with  seltzer,  may  be  given. 

On  the  second  day,  tea,  coffee,  milk-toast,  oyster-stew, 
salt  wafers,  and  chocolate  may  be  added.  On  the  third 
day  after  the  bowels  have  freely  moved  the  amounts  may 
be  increased  and  the  patient  may  have  soups,  thickened 
with  rice,  barley,  etc.,  bread  and  butter,  cereal  foods,  and 
stewed  fruits,  omitting  the  strongly  acid.  In  summer 
ice-cream  and  ices  are  allowable.  On  the  fourth  day  a 
small  piece  of  meat,  as  a chop,  the  breast  of  chicken,  or 
squab,  may  be  given  at  noon.  Fresh  fish  is  also  now 
allowable.  The  other  meals  are  prepared  from  the  diet- 
ary of  the  preceding  days.  On  the  fifth  day  a small 
piece  of  tender  steak,  eggs,  light  puddings,  blanc-mange, 
baked  apple,  jellies,  and  other  delicacies  may  be  given. 
Tea  and  coffee  are  given  sparingly  and  should  not  be 
strong.  Fresh  vegetables  are  allowed  with  salt  or  cream 


DIET 


H3 


dressing,  not  vinegar.  Baked  potatoes,  beans,  and  peas 
are  best  omitted,  as  they  produce  tympany.  Stewed 
fruits,  as  prunes,  dried  apples,  and  peaches,  bran  and 
molasses  biscuits  are  given  for  their  laxative  effect. 
After  the  fifth  day  the  diet  is  as  above,  and  this  has 
been  found  sufficient  for  the  patient  until  she  is  up  and 
about. 

Three  meals  a day  are  served.  At  ten  in  the  morning 
a glass  of  cool  milk,  and  at  three  in  the  afternoon  a cup 
of  chocolate  with  a wafer  are  given  Occasionally  an 
egg-nog  is  prepared  instead  of  the  chocolate  at  three. 
At  midnight,  after  the  nursing,  a glass  of  hot  milk  or 
malted  milk  is  usually  administered. 

Throughout  the  puerperium  the  nurse  will  see  that  the 
patient  drinks  pure  water  freely,  to  make  up  the  loss 
caused  by  the  free  action  of  the  skin  and  kidneys  and 
the  fluid  required  for  making  milk. 

Foods  to  be  Avoided. — Acid  fruits,  as  lemons,  grape- 
fruit, oranges  (sour),  plums,  strawberries,  boiled  toma- 
toes, onions.  These  are  likely  to  cause  colic  in  the  in- 
fant, but  after  a few  weeks  the  mother  should  add  these 
to  her  diet  to  accustom  the  infant  to  them.  Potatoes, 
beans,  peas,  lentils,  and  turnips  cause  flatus  and  tym- 
pany in  the  mother,  and  sometimes  in  the  child,  and 
should  also  be  avoided  until  the  mother  is  up  and  about. 
Highly  spiced  dishes,  heavy  sauces,  spiced  sauces,  dress- 
ings, such  as  French  and  Mayonnaise,  are  all  to  be 
avoided — they  throw  too  much  work  on  the  kidneys. 

Should  the  physician  order  the  liquids  restricted  on 
account  of  the  breasts,  the  nurse  will  leave  out  the  milk, 
tea,  coffee,  chocolate,  and  fresh  fruits,  but  give  a certain 
amount  of  water. 

If  the  patient  has  had  eclampsia  or  is  threatened  with 
it,  the  physician  may  order  milk  and  hot  water  as  the 
sole  articles  of  food. 


144 


CARE  DURING  THE  PUERPERIUM 


The  Bowels.  -Puerperae  are  almost  invariably  con- 
stipated. Strict  attention  must  be  given  to  see  that  the 
patient  has  at  least  one  good  alvine  evacuation  every 
day.  The  nurse  should  ask  the  physician  what  she 
should  do,  getting  minute  instructions.  The  practice 
of  the  Chicago  Lying-in  Hospital  is  as  follows:  On  the 
morning  of  the  second  day  the  patient  receives  i ounce 
of  oleum  ricini  (castor  oil)  suspended  in  whisky  and 
sherry  wine,  or  administered  in  soft  gelatin  capsules. 


Fig.  70. — Castor  oil  in  glass  ready  for  administration. 


To  suspend  the  castor  oil,  as  shown  in  the  illustration 
(Fig.  70),  the  medicine-glass  is  wet  with  the  sherry,  and 
1 dram  of  the  same  left  in  it.  The  oil  is  then  poured  on 
the  sherry,  and,  just  before  the  dose  is  given,  1 dram  of 
whisky  is  flowed  on  top.  The  oil  forms  a ball.  This 
is  followed  in  six  hours  by  a saline  enema.  Every  day 
for  the  first  week  the  patient  receives  a saline  enema,  and 
if  this  does  not  produce  a free  daily  evacuation,  fluid- 
extract  of  cascara  sagrada  in  15-drop  doses  is  given 


THE  BLADDER 


145 


thrice  daily.  The  medicine  is  put  in  empty  capsules 
just  before  it  is  administered.  This  method  is  better 
than  giving  a single  large  dose,  although  sometimes, 
administered  in  this  manner,  the  baby’s  bowels  are 
made  loose.  In  this  case  give  a single  dose  of  30  drops 
after  the  ten  o’clock  nursing,  and  the  effect  on  the  child 
will  be  avoided. 

In  giving  enemata  the  nurse  should  exercise  great  care 
to  avoid  injuring  a sutured  perineum  in  passing  the  rub- 
ber enema-tube.  The  tube  should  be  passed  by  sight, 
under  good  illumination,  and  pressed  downward  at  first 
toward  the  coccyx,  and  then  slightly  upward.  A long 
tube  is  not  necessary.  It  need  pass  only  a few  inches 
beyond  the  anus. 

If  the  breasts  are  too  much  engorged,  a saline  cathar- 
tic— for  example,  effervescent  citrate  of  magnesia—  may 
be  given  instead  of  the  oil,  cascara,  or  enemata,  as  the 
free,  watery  movements  reduce  the  fluids  in  the  breasts. 
If  the  nurse  cannot  get  the  patient’s  bowels  to  move 
properly,  she  should  notify  the  physician.  It  is  of  great 
importance  that  the  bowels  move  freely,  because  some- 
times fever  may  result  from  their  neglect.  Castor  oil  is, 
in  the  writer’s  opinion,  the  best  cathartic  when  adminis- 
tered as  described.  It  was  known  and  cultivated  by  the 
Egyptians  five  hundred  years  before  Christ. 

The  Bladder.  During  labor  the  urethra  and  bladder 
are  bruised  more  or  less.  The  urethra  is  bent  down  and 
sometimes  torn  from  its  attachments,  so  that  there  is 
slight  prolapse,  which  causes  a kinking  of  the  channel. 
As  a result  of  this  and  the  swelling  from  the  contusion, 
plus  the  horizontal  position,  the  patient  cannot  urinate. 
There  may  be  a spasm  of  the  neck  of  the  bladder.  The 
bladder  must  be  emptied  within  ten  hours  after  labor, 
and  at  least  three  times  daily  thereafter,  and  if  the 
patient  cannot  void  urine  the  bladder  must  be  catheter- 
10 


146 


CAKE  DURING  T11E  PUERPERIUM 


ized.  Before  doing  this  several  expedients  should  be 
tried : 

1.  Place  the  patient  on  a warm  douche-pan,  half -full 
of  warm  water,  cover  her,  and  leave  her  alone. 

2.  Allow  the  water  to  run  in  the  wash-stand,  so  that 
she  may  hear  it,  the  patient  being  arranged  on  the  bed- 
pan  as  before;  nurse  leaves  the  room. 

3.  Wet  a large  pledget  of  cotton  with  warm  sterile 
water  and  put  it  on  the  pubis;  the  water  dripping  over 
the  parts  may  start  the  flow  of  urine. 

4.  A hot  fomentation  over  the  bladder,  patient  on 
bed-pan. 

5.  Give  the  patient  a bottle  of  smelling  salts. 

6.  Give  patient  an  enema.  When  the  bowels  move 
the  patient  may  urinate. 

7.  Pressure  over  the  bladder  with  the  hand— gently 
carried  out. 

8.  Raise  the  patient  with  pillows  to  a half-sitting 
position.  Some  physicians  allow  the  patient  to  sit 
up. 

9.  The  catheter. 

With  these  measures  the  nurse  may  use  a little  sug- 
gestion, and  she  should  leave  the  patient  alone,  because 
some  people  cannot  relax  the  sphincter  of  the  bladder 
unless  alone  and  quiet.  The  catheter  should  be  used 
only  when  all  other  means  fail,  because  of  the  great 
danger  of  causing  a cystitis.  Sometimes  a little  glycerin 
applied  to  the  urethra  starts  the  flow,  and  lately  pitui- 
trin  has  been  given  for  the  purpose. 

Catheterization.  -The  nurse  prepares  the  patient  as 
for  a dressing,  sterilizes  her  hands,  and  washes  off  the 
vulva,  and  particularly  the  urethral  orifice,  with  an  anti- 
septic solution.  This  opening  should  be  swabbed  out 
with  lysol  solution,  1 per  cent.,  with  an  applicator.  The 
sterile  rubber  catheter  is  passed  by  sight,  never  by 


GENERAL  TREATMENT 


14  7 


touch,  and  the  urine  is  caught  in  a clean  vessel,  so  as  to 
note  its  character  and  amount. 

Cases  are  rare  where  more  than  one  catheterization 
is  needed,  but  it  may  be  necessary  to  draw  the  urine 
every  eight  hours  for  a few  days.  The  physician  is 
usually  asked  for  permission  to  catheterize;  at  least  he 
should  be  acquainted  with  the  necessity  for  it,  and  per- 
haps he  will  prescribe  a diuretic. 

Sleep.  —It  is  highly  important  that  the  puerpera 
obtain  sufficient  actual  sleep  as  well  as  rest.  One  of  the 
symptoms,  and  perhaps  a cause,  of  puerperal  insanity  is 
lack  of  sleep. 

After  the  patient  has  been  cared  for  on  the  completion 
of  labor  she  is  allowed  to  sleep  as  long  as  possible  and 
the  room  is  darkened  and  quieted  to  favor  this.  Sub- 
sequently the  nurse  must  arrange  the  duties  of  the  day 
so  that  the  puerpera  has  a little  nap  in  the  afternoon  and 
at  least  six  hours  good  sleep  at  night.  If  the  puerpera 
is  persistently  sleepless  the  physician  should  be  notified. 

General  Treatment. — This  is  the  same  as  for  any 
bed  patient  as  regards  bathing,  changing  bed,  and  so 
forth.  Unless  the  weather  makes  it  agreeable,  a full 
bath  is  not  needed  every  day,  but  may  be  given  twice  a 
week.  Daily,  however,  the  whole  body  may  be  sponged 
with  alcohol  and  water,  1 to  3 parts,  paying  especial 
attention  to  the  axillae.  There  should  be  plenty  of  light 
and  fresh  air  in  the  lying-in  chamber.  Sun  and  air  are 
not  harmful  by  any  means.  In  the  olden  time  both  were 
feared,  and  the  puerpera  was  kept  in  semidarkness  all 
the  time,  and  all  air  excluded  to  prevent  her  trom  catch  - 
ing cold.  It  was  thought  that  “catching  cold”  caused 
puerperal  infections  and  mastitis,  but  now  we  know  these 
complications  are  due  to  infection  and  are  in  high  degree 
preventable  by  proper  asepsis.  Free  ventilation  and 
light  are  strong  opponents  to  infection.  The  nurse, 


CARE  DURING  THE  PUERPERIUM 


148 

while  providing  both,  must  see  that  at  no  time  either 
mother  or  child  is  exposed  to  a direct  draft,  and  that  the 
bright  light  does  not  fall  directly  on  the  eyes  of  either. 

After  the  first  week  the  nurse  may  give  the  patient  a 
general  light  massage.  She  should  avoid  the  inside  of 
the  legs,  where  there  are  veins,  and  the  uterus  and 
breasts.  Passive  motions  of  the  arms,  legs,  and  trunk 
are  also  sometimes  recommended.  These  exercises 
while  away  the  tedium  of  the  bed,  improve  the  circula- 
tion, and  hasten  the  return  of  the  patient’s  strength. 

The  temperature,  pulse,  and  respiration  should  be 
taken  at  least  three  times  a day — about  7 a.  m.,  3 and 
10  p.  m. — and  record  made  of  them  on  the  history- 
sheet.  Other  points  to  be  noted  are  how  much  the 
patient  has  slept,  her  general  condition,  also  her  diet, 
enemata  and  bowel  movements,  catheterizations,  the 
number  and  amount  of  urinations,  all  medicines  given, 
the  doctor’s  visits,  and  all  unusual  occurrences. 

Visitors.  -The  lying-in  room  should  be  quiet  and 
restful.  The  puerpera  must  be  given  opportunity  to 
recover  from  the  strain  of  labor  and  recuperate  her 
strength  from  the  exhaustion  of  pregnancy  and  delivery. 
Therefore  only  the  nearest  relatives  are  to  be  allowed  in 
the  lying-in  chamber  during  the  first  week.  Even  these 
visits  should  be  very  short.  Aside  from  the  nervous 
disturbance  caused  by  too  many  visitors,  there  is  the 
danger  of  the  introduction  of  contagion. 

The  Time  of  Getting  Up. — This  varies  in  the  prac- 
tice of  different  physicians.  While  most  accoucheurs 
allow  the  woman  to  get  out  of  bed  on  the  tenth  day, 
others  allow  this  only  in  the  third  or  fourth  week.  A 
very  few  physicians  allow  the  women  to  get  up  when 
they  feel  able  for  it,  even  if  it  is  the  second  day.  The 
attending  physician  will  specify  what  the  nurse  should  do 
in  these  cases.  The  writer’s  practice  is  to  allow  the 


GENERAL  TREATMENT 


1 49 


woman  to  sit  up  in  bed  on  the  ninth  day,  to  get  out  into 
a rocker  or  Morris  chair  on  the  tenth,  stand  on  her  feet 


Fig.  71. — Mother  nursing  infant  when  out  of  bed.  A low  rocker  without  arms 
and  a low  foot-stool  provide  an  unstrained  attitude. 


on  the  eleventh,  have  the  freedom  of  the  room  on  the 
twelfth,  and  go  down  stairs  on  the  fifteenth  day.  In 
operative  cases  these  acts  are  postponed  a day  or  two, 


So 


CARE  DURING  THE  PUERPERIUM 


depending  on  the  patient’s  strength.  Nurses  say  that 
while  the  women  are  physically  able  to  get  up  at  the  end 
of  the  second  week,  their  getting  out  of  bed  brings  a 
host  of  callers  and  household  duties  which  are  too  great 
a strain,  therefore  it  is  better  for  the  puerpera  to  stay 
an  extra  time  in  bed  recuperating. 

When  the  patient  gets  up  she  should  wear  the  abdomi- 
nal binder,  and  in  some  cases  a binder  or  jockey  strap 
may  be  worn  for  several  weeks  with  comfort.  Corsets 
may  be  resumed  after  the  fourth  week. 

Occasionally  the  lochia  rubra  reappear  on  arising  from 
bed.  In  such  an  event  a rest  on  the  couch  for  a few 
days  will  bring  relief.  If  not,  the  physician  is  to  be 
notified. 

The  first  menses  after  labor,  usually  about  the  sixth 
week,  are  likely  to  be  very  profuse.  Recovery  is  the 
rule. 

The  patient  may  take  a tub-bath  after  the  third  week. 

Nursing-  After  the  Patient  is  Up. — The  breasts 
should  be  supported  by  a light  breast-binder  or  sup- 
porter. The  same  aseptic  care  is  practised  as  when  the 
puerpera  was  in  bed,  as  mastitis  may  come  on  at  any 
time  during  lactation.  The  woman  is  warned  about 
infection  and  instructed  how  to  prevent  it.  When  up 
the  mother  holds  her  infant  as  in  Fig.  71,  sitting  on  a 
low  rocker,  a shawl  over  her  shoulders  and  her  foot  on  a 
low  stool. 


CHAPTER  III 


CARE  OF  THE  CHILD 

The  child  is  usually  kept  in  its  basket  in  the  mother’s 
room  during  the  day,  but  at  night  it  is  taken  to  an  ad- 
joining apartment,  so  as  to  allow  the  mother  to  rest. 

Visitors. — None  but  the  husband,  father,  and  the 
mother  or  other  near  relative  are  allowed  in  the  lying-in 
chamber  for  the  first  week.  After  this  a few  near  friends 
are  admitted.  The  nurse  must  be  assured  that  no  visitor 
is  allowed  to  enter  who  has  been  near  a contagious  dis- 
ease, as  measles,  scarlatina,  diphtheria,  la  grippe,  “cold 
in  the  head,”  or  pus  cases,  carbuncles,  etc.  Altogether, 
the  puerpera  should  not  be  required  to  make  too  fre- 
quent effort  to  receive  visitors,  and  the  nurse  may  do 
much  by  tactfully  reducing  the  number  and  length  of 
the  visits.  Further,  the  child  must  not  be  disturbed 
by  being  exhibited  to  curious,  if  friendly,  neighbors  and 
relatives. 

Bathing". — Until  the  umbilicus  is  healed  the  child 
should  not  be  put  in  the  full  bath.  Daily  the  head  and 
face  are  sponged  with  lukewarm  water,  using  a little 
Castile  soap  if  necessary.  The  buttocks  when  soiled  are 
sponged  with  cool  water.  The  body  is  gently  rubbed 
with  benzoinated  lard;  this  is  removed  by  means  of  a 
soft  towel,  which  is  usually  all  that  is  needed  to  keep  the 
infant  sweet  and  clean.  After  the  cord  is  off  and  navel 
cicatrized  the  child  is  given  a full  bath.  In  summer  the 
child  may  be  given  a sponge-bath  instead  of  the  oiling, 
because  the  perspiration  and  fat  macerate  the  skin. 

151 


152 


CARE  OF  THE  CHILD 


Ordinarily  no  dusting-powder  is  needed,  but  if  the 
infant  shows  a tendency  to  chafe — that  is,  if  there  is  any 
intertrigo — a powder  of  stearate  of  zinc  should  be 
evenly  applied  after  the  bath.  Much  powder  should  not 
be  used,  and  no  friction  is  to  be  employed,  because  this 
rubs  off  the  delicate  epithelium.  Where  the  skin  is 


Fig.  72. — Arrangements  for  bathing  the  infant. 


already  eroded,  no  friction  is  at  all  allowable,  the  nurse 
laying  the  cloth  on  the  skin  and  rubbing  her  finger  over  it 
similarly  to  the  use  of  an  ink-blotter.  In  obstinate  cases 
the  physician  will  prescribe  an  ointment.  The  nurse 
should  pay  especial  attention  to  the  ears,  the  palms,  the 
axillae,  and  the  groins,  and  in  girls  take  care  not  to  injure 
the  external  genitals.  To  remove  the  whitish  secretions 


BATHING 


53 


which  sometimes  accumulate  in  the  little  labial  folds, 
albolene  is  very  successful.  The  nostrils  are  cleaned 
with  cotton  wrapped  smoothly  on  a tooth-pick  (an  ap- 
plicator), after  softening  the  mucus  with  benzoinated 
lard  or  albolene. 


Fig-  73- — Proper  method  for  holding  the  infant  during  the  bath.  The 
fingers  and  thumb  are  distributed  over  the  head  and  shoulders,  so  that  the 
child  cannot  slip  out,  and  also  when  it  kicks  that  it  cannot  strike  its  head  against 
the  sides  of  the  tub.  The  thermometer  may  be  removed  after  the  child  is  im- 
mersed. 


In  hospitals,  where  there  is  danger  of  carrying  an  in- 
fection on  the  skin,  such  as  pemphigus  or  gonorrhea, 
from  one  child  to  another,  special  precautions  are  neces- 
sary: First,  the  nurse  must  watch  for  and  report  at 
once  to  her  superior  any  eruption  or  sore,  however 
slight,  on  the  infant,  and  note  the  same  on  her  record. 


54 


CARE  OF  THE  CHILD 


Second,  the  nurse  individualizes  the  babies  as  much  as 
possible,  i.  e.}  she  disinfects  her  hands  and  the  tub, 
uses  a sterile  washcloth,  etc.,  for  each  infant.  Third, 
she  isolates  a child  under  suspicion,  provides  separate 
tub,  lard,  clothes,  etc.,  dresses  it  wearing  rubber  gloves, 
or  delegates  these  duties  to  another.  Its  clothes  are 
thrown  into  a 3 per  cent,  carbolic  solution  before  being 
sent  to  the  laundry.  Only  by  extreme  care  can  spread- 
ing of  the  infection  be  prevented. 

Care  of  the  Navel. — The  original  dressing  is  allowed 
to  remain  as  long  as  possible.  If  the  babe  is  oiled,  not 
bathed,  or  given  only  a half-bath  each  day,  it  is  seldom 
necessary  to  change  the  cord  dressing.  This  should  be 
done  whenever  it  is  displaced  or  soiled  by  urine.  The 
gauze  is  soaked  off  with  1 : 2000  bichlorid  solution, 
washed  with  same  or  70  per  cent,  alcohol,  and  dressed 
again  with  dry  sterile  gauze.  If  the  cord  is  moist,  a 
thorough  washing  with  95  per  cent,  alcohol  will  improve 
it.  No  powders  are  used  unless  ordered  by  the  physician. 
In  this  manipulation  the  nurse  need  touch  the  cord 
only  with  the  cotton  pledget.  The  navel  is  treated 
exactly  as  a surgical  wound. 

The  binder  must  be  smoothly  adjusted  and  sewed  on, 
taking  care  that  it  is  not  too  tight,  impeding  the  infant’s 
respiration.  The  nurse  should  observe  and  note  the 
conditions  of  the  cord,  whether  it  is  moist  or  dry,  whether 
the  line  of  separation  is  red  and  angry  or  clean  and  pink; 
whether  or  not  there  is  a purulent  discharge;  if  there  be 
any  odor — in  other  words,  whether  the  navel  is  healing 
properly  or  not.  (See  Plate  III,  opposite  page  351.) 

The  falling  off  of  the  cord  should  be  noted,  and  the 
antiseptic  treatment  of  the  wound  continued  until  it  is 
cicatrized  and  healed  over.  Occasionally  a little  bloody 
oozing  comes  from  the  cord  or  from  the  surface  left 
after  it  separates.  The  doctor  may  prescribe  the  appli- 


THE  EYES 


55 


cation  of  a little  powdered  alum  to  the  spot,  or  a mix- 
ture of  starch  and  alum. 

The  Eyes.  -There  are  two  important  injunctions 
regarding  the  eyes : the  first  is  to  prevent  infection  from 
getting  into  them,  and  the  second  is  to  avoid  mechanical 
injury,  as  the  wiping  of  rough  sleeves,  scratching  with 
rough  clothes,  or  too  brisk  manipulations. 

During  the  oiling  or  bath  extreme  care  must  be  exer- 
cised to  prevent  fluid  getting  into  the  eyes,  and  this  pre- 
caution must  be  observed  throughout  the  puerperium. 
The  skin  of  the  infant  may  be  infected  with  gonorrheal 
virus,  and  this,  getting  into  the  eyes,  sets  up  severe  in- 
flammation, which  may  cause  blindness. 

If  the  Crede  method  for  preventing  ophthalmia  neo- 
natorum has  been  used,  there  may  be,  in  three  to  six 
hours,  some  inflammatory  reaction  of  the  eyelids,  with 
redness,  swelling,  and  seropurulent  secretion.  No  alarm 
need  be  felt  at  this.  Cold  applications  to  the  lids  and  a 
few  irrigations  of  the  conjunctival  sac  with  2 per  cent, 
boric  acid  or  normal  salt  solution  will  relieve  it.  If  a 
freshly  made  nitrate  solution  is  used  such  reactions  are 
exceptional. 

Every  morning  the  nurse  washes  the  outsides  of  the 
lids  with  cotton  wet  in  saturated  solution  of  boric  acid. 

In  normal  cases  this  care  is  all  that  is  needed,  but 
should  there  be  a continued  mucopurulent  discharge 
which  glues  the  lids  together,  this  must  be  gently  soaked 
off  with  warm  boric  solution  and  the  eyes  irrigated  with 
the  same  several  times  daily.  Should  a slight  conjuncti- 
vitis resist  this  mild  treatment,  the  doctor  will  prescribe 
a collyrium  of  sulphate  of  zinc  or  similar  astringent,  or 
one  of  the  newer  preparations  of  silver,  as  protargol  or 
argyrol. 

If  on  the  second  day  or  later  a thin,  cloudy  discharge 
appears  between  the  lids  and  runs  down  the  cheek,  and 


56 


CARE  OF  THE  CHILD 


the  lids  become  swollen  and  of  deep  red  color,  little  floc- 
culi  of  fibrinopus  being  seen  on  them,  the  case  is  serious; 
the  physician  must  be  notified  at  once  by  telephone,  be- 
cause the  case  is  one  of  ophthalmia  neonatorum  and 
requires  instant  and  vigorous  treatment.  (See  pages 

347-352-) 

The  Bowels.  —Unless  the  meconium  is  thoroughly 
evacuated,  it  is  a good  plan  to  give  the  infant  castor  oil  at 


Fig.  74. — Rectal  irrigator.  A simple  funnel  will  answer  as  well. 


the  same  time  the  mother  takes  hers — that  is,  on  the 
morning  of  the  second  day.  If  the  bowels  do  not  move 
freely,  this  is  the  best  cathartic  for  infants.  The  castor 
oil  is  dropped  into  the  child’s  mouth  from  a medicine- 


THE  BOWELS 


57 


dropper,  not  given  from  a spoon.  Only  in  this  way  can 
one  be  sure  the  infant  obtains  the  right  dose. 

The  nurse  should  observe  closely  the  number  and 
character  of  the  bowel  movements,  and  note  the  same 
on  her  history-sheet.  The  condition  of  the  infant  is 
read  from  the  bowel  movements.  If  the  infant  is  rest- 
less and  colicky,  with  audible  borborygmus  (rumbling 
in  the  bowels),  a colonic  flushing  of  normal  salt  solution 
(0.6  per  cent.)  may  be  given.  This  is  done  with  a soft- 
rubber  catheter  (size  No.  10  or  12  American  scale),  to 
which  is  attached  a little  funnel  or  the  barrel  of  a glass 
syringe  (Fig.  74).  The  salt  solution  is  allowed  to  run  in 
and  out,  2 or  3 ounces  at  a time,  for  five  or  ten  minutes, 
until  the  bowel  is  well  cleansed  and  evacuated.  The 
room  should  be  warm  and  the  infant  exposed  as  little  as 
possible.  The  tube  and  funnel  are  boiled  and  sterile 
water  used  to  make  the  salt  solution. 

The  child  is  laid  on  its  side  across  the  nurse’s  knee. 
A rubber  drainage  sheet  is  arranged  under  the  buttocks 
of  the  infant,  and  thus  the  discharges  are  conducted 
into  a jar  on  the  floor  (Fig.  75).  A catheter  cannot 
be  passed  very  far  into  the  sigmoid  flexure,  and  an 
attempt  to  do  so  is  dangerous.  If  the  tube  is  inserted 
beyond  the  sphincter,  it  is  enough.  Anything  un- 
usual (blood,  mucus)  is  to  be  saved  for  the  physician’s 
inspection. 

If  the  bowel  movements  are  acrid  and  irritating,  the 
anal  region  may  become  deeply  eroded.  This  can 
almost  always  be  prevented,  but  if  the  condition  of  the 
bowels  cannot  be  improved,  and  especially  if  the  baby  is 
fed  by  the  bottle,  the  disease  is  obstinate  and  hard  to 
cure.  There  is  danger  in  allowing  the  buttocks  to  be- 
come sore — danger  of  infection. 

When  the  diaper  is  changed  the  buttocks  and  thighs 
are  sponged  off  with  a soft  cloth  and  cool  water,  using 


58 


CARE  OF  THE  CHILD 


little  and  gentle  friction.  If  the  skin  is  healthy,  no 
powder  is  needed,  but  if  there  are  redness  and  beginning 


Fig.  75. — Giving  a colonic  flushing.  The  infant  rests  on  its  left  side,  warmly 
covered.  A towel  covers  the  rubber  drainage  sheet. 


irritation,  stearate  of  zinc  powder  is  applied,  although 
not  enough  to  form  flakes. 


UR  IN  A TION 


159 


If  an  erosion  forms  or  threatens,  no  water  at  all  may 
be  used,  but  the  buttocks  are  cleansed  with  the  finest 
olive  oil  procurable  (not  vaselin),  and  the  excess  is  re- 
moved with  gentle  pressure  with  an  old  linen  towel  or 
lintine.  The  cloth  is  used  as  one  would  use  an  ink- 
blotter.  The  stearate  of  zinc  is  also  sometimes  useful 
here,  but  if  it  fails,  the  pure  oxid  of  zinc  ointment  may 
be  applied.  The  physician’s  advice  should  be  asked 
regarding  all  erosions,  as  they  may  indicate  a constitu- 
tional taint.  These  instructions  are  not  to  take  the  place 
of  the  physician’s  prescription,  but  are  given  to  those 
nurses  who  have  to  do  much  on  their  own  responsibility. 

Attention  to  the  intestinal  tract  is  of  prime  import- 
ance in  preventing  and  curing  this  “chafe,”  or  eczema 
intertrigo. 

The  Diaper. — It  is  important  to  have  a large,  thick, 
soft  diaper,  flatly  folded  and  smoothly  applied.  Gauze 
diapers  are  useful  for  the  first  week.  The  use  of  rubber 
sheeting  to  prevent  soiling  the  dress  is  bad;  for  this  pur- 
pose an  extra  diaper  should  be  wrapped  around  the 
trunk  of  the  infant. 

The  diapers  should  be  scrupulously  clean,  and  soap 
alkali  and  washing-powder  thoroughly  rinsed  out  of 
them.  If  strong  soaps  are  not  thoroughly  taken  out  of 
the  fabric  in  the  laundry,  they  irritate  the  delicate  skin 
of  the  babe  and  may  cause  eczema.  The  same  may  be 
said  of  all  the  infant’s  clothes.  A diaper  wet  with  urine 
must  be  washed  in  water  and  dried  before  being  used 
again.  Even  though  the  infant’s  urine  is  clear,  when 
dried  it  gives  off  an  odor  and  is  irritating.  In  boys  the 
diaper  must  be  applied  a little  differently  than  in  girls, 
care  being  taken  that  the  parts  are  not  pressed  into  an 
uncomfortable  position. 

Urination. — The  infant  should  urinate  freely,  and, 
since  it  does  so,  is  often  wet.  Unless  the  diaper  is 


6o 


CARE  OF  THE  CHILD 


frequently  changed  the  skin  will  macerate  and  the  nates 
become  sore  or  chafed.  The  nurse  should  insist  on  hav- 
ing washed  diapers  for  the  infant.  If  the  urine  is  allowed 
to  dry  on  them,  the  salts  concentrate  and  irritate  the 
tender  skin. 

If  the  child  passes  the  reddish  brick-dust  sediment 
described  before  and  known  as  uric  acid,  this  should  be 
noted;  it  calls  attention  to  the  fact  that  the  child  needs 
more  water. 

If  the  child  does  not  urinate  within  a few  hours  after 
birth,  the  nurse  should  carefully  inspect  the  parts  to 
determine  the  existence  of  any  abnormality  of  structure. 
If  she  suspects  such,  the  physician  should  be  notified. 

In  order  to  get  the  infant  to  urinate,  it  should  be  given 
water  freely;  then  it  should  be  held  sitting  in  a bowl  of 
warm  water  for  five  minutes;  a warm  fomentation  over 
the  kidneys,  a prolonged  saline  solution  colonic  flushing 
— all  these  may  be  used  to  stimulate  the  flow  of  urine. 
The  condition  may  go  thirty-six  hours  without  danger. 
In  one  case  the  infant  passed  no  urine  for  three  days  and 
did  not  suffer.  Catheterization  is  necessary  only  in  the 
rarest  cases.  It  must  be  remembered  that  the  child  may 
urinate,  unobserved,  in  its  bath,  or  the  urine,  being 
colorless,  leaves  no  stain  on  the  diaper  and  evaporates 
before  the  nurse  notices  the  latter.  If  the  condition 
is  obstinate,  the  physician  will  usually  order  a diuretic, 
of  which  the  sweet  spirit  of  niter  is  a favorite. 

Nursing*. — The  child  should  be  put  to  the  breast 
after  the  mother  has  rested,  which  is  usually  about 
eight  hours  after  birth,  then  every  four  hours  until  the 
milk  comes  in,  then  every  three  hours  during  the  day 
and  once  during  the  night.  The  best  hours  to  choose 
depend  on  circumstances.  In  the  home,  7 and  10  A.  M.,  1, 
4,  7,  and  10  p.  m.,  and  once  about  2 or  3 a.  m.,  are  usually 
the  best.  Before  and  after  each  nursing,  if  necessary,  the 


NURSING 


6l 


diaper  is  changed.  Occasionally,  if  the  tongue  is  coated 
it  may  be  cleaned  with  cotton  pledgets  wrapped 
around  the  finger  and  saturated  with  boric  solution. 
The  nurse  should  be  careful  not  to  scratch  the  delicate 
mucous  membrane,  as  it  may  easily  be  infected.  Should 
the  whitish  pellicle  on  the  tongue  not  come  off  readily,  a 
pinch  of  baking-powder  on  the  surface  will  accomplish 
it.  The  mouth  requires  no  routine  treatment.  To  try 
to  disinfect  the  child’s  mouth  to  prevent  breast  infection 
is  futile.  In  fact,  the  writer  believes  such  attempts 
favor  infection  by  making  sores  in  the  mouth  at  the  angle 
of  the  jaws.  Before  nursing  the  nipple  is  washed  with 
boric  solution  on  an  applicator,  and  afterward  likewise, 
and  if  there  is  any  soreness  at  all,  the  nipple  is  anointed 
with  albolene  or  cocoa-butter.  Neither  before  nor  after 
nursing  is  the  infant’s  mouth  to  be  washed.  Each 
nursing  should  last  not  over  fifteen  minutes,  and  the 
infant  must  be  watched  to  see  that  it  gets  enough.  The 
babe  must  suck  and  swallow  too.  If  the  breast  is  dry  the 
child  will  suck,  but  will  have  nothing  to  swallow.  A 
good  supply  is  shown  by  the  milk  running  out  of  the 
infant’s  mouth.  It  must  not  be  allowed  to  sleep  at  the 
breast,  because  this  macerates  the  nipple  and  favors  the 
formation  of  cracks,  which  may  easily  lead  to  infection 
and  mastitis. 

By  adhering  to  these  rules  the  child  soon  learns  cor- 
rect habits,  which  make  the  whole  period  of  infancy 
healthier  and  less  troublesome. 

In  the  long  intervals  between  nursings  the  child  may 
need  a little  warm  water,  but  not  more  than  3 ounces 
a day,  and  it  should  not  get  into  the  habit  of  water- 
tippling — lying  with  the  bottle  in  its  mouth  all  night. 
Some  children  do  not  take  to  the  nipple  well,  but  fret 
and  fuss  over  the  nursing.  This  is  sometimes  due  to  too 
full  breasts,  a small  or  flat  nipple,  or  because  the  milk 
11 


1 62 


CARE  OF  TIIE  CHILD 


does  not  agree  with  the  child,  or  because  there  is  none 
there.  Sometimes  the  milk  is  salty  or  bitter,  which  may 
be  true  of  only  one  breast,  or  the  milk  may  flow  readily 
from  one  breast  and  not  from  the  other.  The  child  will 
prefer  the  easier  side  always. 

Various  expedients  may  be  tried  to  get  the  child  to 
nurse:  First,  squeeze  a little  milk  in  the  child’s  mouth. 
Second,  put  a nipple-shield  (Fig.  76)  full  of  sterile  water 
over  the  nipple;  the  child  will  empty  this,  and  will 


into  the  child’s  mouth.  Sixth,  pump  the  milk  and  feed 
the  child  from  a bottle  until  it  is  stronger  and  feels  the 
sensation  of  hunger. 

The  nurse  must  be  convinced  that  the  child  gets  suffi- 
cient nourishment.  If  there  is  no  milk  in  the  breast 
the  child  swallows  air,  and  then  suffers  both  colic  and 
hunger.  Some  infants,  especially  little  ones,  fall  asleep 
after  nursing,  and  are  “good  children,”  but  lose  weight 
steadily  and  die  of  marasmus.  If  there  is  any  doubt 
about  the  child  getting  enough  milk  at  each  nursing, 
it  should  be  accurately  weighed  before  and  after  being 
put  to  the  breast.  These  weights  are  recorded,  and  the 
difference  represents  the  amount  swallowed.  It  is 


Fig.  76.— Glass  nipple- 
shield. 


learn  to  suck  the  milk  following. 
Third,  put  a hot  wet  compress 
over  the  nipple  for  a few  minutes 
before  nursing  to  bring  the  “milk 
to  the  surface” — really  to  facilitate 
the  making  of  milk.  Fourth,  start 
the  flow  with  a breast-pump  (Fig. 
77),  and  then  put  the  infant  to 
the  breast.  Fifth,  use,  especially 
if  the  child  is  weak  or  premature, 
the  teterelle.  (See  Fig.  196.) 
The  mother  sucks  the  milk  into 
the  bulb  and  then  allows  it  to  run 


NURSING 


A 2 

°3 


Fig.  77. — Breast-pump.  Chicago  Lying-in  Hospital  pattern.  Diagram  shows 
method  of  using  it.  Rubber  bulb  must  always  be  vertical,  so  that  milk  never 
gets  into  it.  One  should  pump  with  short,  gentle  squeezes,  not  to  exhaust  all 
the  air,  but  to  imitate  the  sucking  of  the  infant.  Only  the  glass  portion  of  the 
apparatus  need  be  boiled. 


164 


CARE  OF  THE  CHILD 


not  necessary  to  undress  the  babe  for  these  weighings. 
Adding  these  amounts  for  twenty-four  hours  gives  the 
daily  amount  of  nourishment.  Herewith  is  a table  show- 
ing the  daily  amounts  taken  by  an  infant  for  the  first 
three  weeks: 


TABLE1 


Number  of 
Nursings. 

Average  Amount 
Drunk  at 
Each  Nursing. 

, Total  Grams. 

Total  Ounces. 

1st 

day 

2 

2.5  grams 

5.0  grams 

1 I? 

drams 

2(1 

“ 

5 

29.0  “ 

145.0 

u 

4f 

ounces 

3d 

“ 

6 

41.0  “ 

246.0 

8* 

U 

4th 

CC 

7 

58.8  “ 

411.6 

13I 

u 

5th 

CC 

6 

67-5  “ 

405.0 

135 

(C 

6th 

“ 

7 

73-o  “ 

511.0 

a 

17 

u 

7th 

“ 

6 

£ £ 

92.2 

553-2 

u 

i8| 

“ 

8th 

“ 

7 

97.0  “ 

679.0 

“ 

22I 

ic 

9th 

“ 

6 

93-o  “ 

558.0 

(C 

i8f 

a 

10th 

“ 

7 

86.0  “ 

692.0 

“ 

23 

“ 

nth 

“ 

6 

96.0  “ 

576.0 

“ 

195 

cc 

12th 

“ 

6 

93-o  “ 

558.0 

“ 

i8f 

a 

13th 

cc 

7 

86.0  “ 

602.0 

20 

cc 

14th 

“ ... 

7 

91.0  “ 

637.0 

“ 

214 

u 

15th 

“ 

6 

93-o  “ 

558.0 

u 

i8f 

“ 

1 6 th 

u 

7 

90.0  “ 

630.0 

11 

21 

u 

17th 

“ 

7 

92.0  “ 

644-0 

(C 

2l| 

u 

1 8th 

“ 

6 

96.0  “ 

576.0 

“ 

i9i 

cc 

19th 

u . 

7 

105.0  “ 

1 735-o 

24I 

u 

20th 

“ . 

6 

112.0  “ 

672.0 

“ 

22\ 

u 

2ISt 

i 7 

102.0  “ 

j 714.0 

u 

23f 

The  Diet. — For  the  first  few  days  there  is  nothing 
but  colostrum  in  the  breasts  and  the  baby  gets  this. 
The  colostrum  is  laxative,  because  indigestible.  The 
child  needs  water  besides,  which  should  be  given  every 
two  hours,  1 ounce  at  a time.  Most  children  are  satis- 
fied with  these  for  the  first  two  days,  but  sometimes  it  is 
necessary  to  administer  food  and  water,  and  unless  these 
are  given  the  child  will  fret,  cry,  even  develop  fever — 
the  so-called  “starvation  or  thirst  fever.”  One  must 

1 This  table  is  from  Ahlfeld,  and  was  from  his  own  child. 


THE  DIET  165 

be  very  careful  not  to  call  all  fevers  of  the  newborn 
starvation  fevers,  because  most  of  them  are  due  to  sep- 
sis— intestinal,  bronchial,  or  from  the  navel  or  throat. 

A fever  later,  especially  when  the  child  is  on  artificial 
food,  is  often  due  to  intestinal  fermentation,  and  sub- 
sides after  castor  oil  and  a colonic  flushing  have  been  ad- 
ministered. In  a maternity  hospital  the  child  can  obtain 
nourishment  for  the  first  few  days  from  one  of  the 
nursing  women  in  the  wards,  but  in  private  practice,  if 
the  mother  has  no  milk,  artificial  food  must,  if  needed, 
be  substituted.  A dram  of  cream  to  an  ounce  of  water, 
or  weak  milk  of  “peptogenic  powder”  may  be  given  to 
tide  the  infant  over  until  the  secretion  in  the  mother’s 
breasts  is  established.  Before  putting  a child  to  any 
breast  but  that  of  its  mother , the  nurse  must  know  that 
neither  is  syphilitic  nor  otherwise  diseased. 

After  the  milk  comes  these  foods  should  be  discon- 
tinued. Should  the  mother  permanently  have  no  milk, 
or  not  enough,  or  milk  of  poor  quality,  artificial  feeding 
must  be  resorted  to,  which  is  really  a great  calamity,  or 
a wet-nurse  must  be  procured,  which  is  the  lesser  of  the 
two  evils.  It  is  hard,  sometimes  impossible,  to  find  a 
good  wet-nurse,  in  which  case  the  child  must  be  given 
artificial  food — a difficult  and  often  unsatisfactory  task. 
The  nurse  should  urge  the  mother  to  nurse  her  infant,  and 
only  give  up  in  the  presence  of  real  danger  to  herself  or 
because  the  milk  does  not  agree  with  the  baby.  Re- 
markable as  it  may  seem,  the  milk  of  some  mothers  acts 
like  an  irritant  intestinal  poison  to  the  infant  and  may 
produce  enteritis  or  even  death. 

If  there  is  a scarcity  of  mother’s  milk,  one  may  try  to 
stimulate  the  glands,  first,  by  daily  massage,  cold  bathing 
of  the  whole  body,  giving  much  fluid  to  drink — espe- 
cially milk,  water,  cocoa,  gruels,  and  oyster-stews,  but  no 
tea,  coffee,  beer,  or  malt  liquors.  The  two  last  fatten  the 


CARE  OF  THE  CHILD 


1 66 

patient  and  reduce  the  milk-supply.  A strong  baby  is 
the  best  stimulant  to  the  breasts,  and  if  this  fails  to 
bring  milk,  usually  there  is  no  gland  tissue  there,  and  all 
efforts  will  be  futile.  Occasionally  the  milk-supply  is 
not  abundant  until  the  patient  is  up  and  about  and  takes 
out-door  exercise. 

If  the  baby  must  be  reared  on  the  bottle,  the  first  dif- 
ficulty is  to  select  the  proper  food,  and  infants  show 
remarkable  peculiarities  in  this  way.  Some  will  thrive 
on  a preparation  that  seems  to  poison  the  next.  Medical 
opinion  also  sways  from  one  kind  of  feeding  to  another. 
(See  chapter  on  Infant  Feeding.) 

If  the  mother  can  give  the  baby  only  one  nursing  a 
day,  she  should  do  so,  because  there  is  something  in 
mother’s  milk  that  the  finest  chemistry  cannot  find  nor 
imitate — a life-giving  something — and  it  helps  the  baby 
to  digest  and  assimilate  the  supplied  food. 

Weighing  the  Infant.— The  child  should  be  weighed 
directly  after  birth;  it  should  be  naked,  but  protected 
from  the  cold.  Thereafter,  every  day  before  its  bath, 
its  weight  should  be  taken  and  recorded. 

The  scale  used  should  be  an  “even  balance”  grocer’s 
scale,  with  a scoop  on  one  side  and  iron  weights  on  the 
other  (Fig.  48).  A sliding  weight  on  a scale-bar  in  front 
gives  the  ounces.  The  scoop  should  be  wired  fast  to  its 
supports,  so  that  the  infant  cannot  shake  it  off.  A 
napkin  is  placed  in  the  scoop,  and  one  of  exactly  the 
same  size  is  folded  up  on  the  weight  plate.  These 
balance,  and  the  actual  weight  of  the  infant  is  thus 
easily  obtained. 

If  there  is  any  suspicion  that  the  child  does  not  obtain 
enough  nourishment  from  the  mother,  it  should  be 
weighed  before  and  after  each  nursing,  and  the  differ- 
ence will  show  how  much  the  babe  has  ingested.  The 
amount  varies  with  the  age  of  the  infant — 1 or  2 drams 


TRAINING  THE  BABY 


67 


the  first  few  days  to  2 or  3 ounces  by  the  tenth  day;  it 
varies  in  different  infants,  some  taking  less  than  others, 
this  being  governed  somewhat  by  the  child’s  size,  and 
it  varies  at  different  nursings,  a large  nursing  usually 
being  followed  by  a lighter  one,  which  means  that  the 
appetite  of  the  child  varies. 

The  Temperature,  Pulse,  and  Respiration.— 
These  should  be  taken  A.  m.  and  p.  m. — certainly  the 
temperature,  and,  when  possible,  the  others  also.  The 
infant  should  have  a record-sheet  of  its  own,  and  all 
notable  occurrences  recorded.  It  is  very  difficult  to 
count  the  respirations,  and  even  normally  they  are  irregu- 
lar. With  a little  practice  the  pulse  can  be  readily 
counted,  the  best  place  being  just  in  front  of  the  ear  and 
when  the  child  sleeps.  The  radial  pulse  is  also  sometimes 
countable. 

The  room  in  which  the  child  lies  should  be  airy,  and 
kept  at  a temperature  of  about  720  F.  It  must  be  light, 
but  the  infant  must  not  lie  in  too  bright  a glare.  The 
child’s  feet  are  often  cold,  so  a hot-water  bag  must  be 
used,  sometimes  even  in  summer.  The  bag  should  be 
warm,  not  hot,  so  as  not  to  burn  the  infant.  The  child 
must  not  lie  with  dresses  moist  from  urination  or  vom- 
iting, from  a leaky  hot-water  bag,  or  from  a bottle 
given  it  to  drink. 

All  these  precautions  are  especially  necessary  with 
premature  or  weak  infants. 

Training  the  Baby. — The  infant  must  not  be  dis- 
turbed except  for  needed  attention  and  for  nursing.  It 
must  not  be  on  show  to  all  the  relatives  and  friends.  It 
must  be  handled  carefully,  and  when  being  lifted  up  the 
head  must  always  be  supported  and  not  allowed  to  fall  to 
the  back  or  side.  When  bathing  the  child  the  large 
abdomen  or  breasts  must  not  be  pressed  too  hard. 
After  nursing  the  child  must  not  be  jarred,  because  it 


1 68  CARE  OF  THE  CHILD 

may  regurgitate  the  milk.  The  nurse  must  not  allow 
the  infant  to  get  into  bad  habits—  for  example,  water- 
tippling,  peppermint-tippling,  sucking  on  a nipple  or 
the  finger,  water-  and  whisky-tippling,  sleeping  with  its 
mother  or  other  person,  being  taken  up  when  it  cries, 
held,  rocked,  or  carried,  etc. 

By  proper  training  the  child  may  be  taught  to  sleep 
nearly  the  whole  night  through,  to  sleep  between  nurs- 
ings, and  to  cry  only  when  hungry,  uncomfortable,  or 
sick.  Adherence  to  the  above  rules  will  bring  this 
about. 


CHAPTER  IV 


PRESENTATIONS  AND  POSITIONS 

Heretofore  labor  has  been  spoken  of  as  if  it  occur- 
red with  the  child  always  presenting  by  the  head.  Such 
is  by  no  means  the  case.  The  fetus  may  present  any 
part  of  its  body  to  the  parturient  passage. 

The  term  “presentation”  has  reference  to  that  part  of 
the  fetus  which  presents  itself  at  the  internal  os  first  for 
delivery.  The  most  common  presentations  are  occipital, 
breech,  shoulder,  face,  and  brow.  Of  all  presentations, 
96  per  cent,  are  occipital  and  2J  per  cent,  are  breech. 

In  order  to  study  the  mechanism  of  labor  the  phys- 
ician must  know  what  position  the  child  holds  in  relation 
to  the  mother’s  pelvis. 


Fig.  78. — Diagram  of  the  four  quadrants  of  the  pelvis. 

The  pelvis,  therefore,  is  divided  into  four  quadrants  as 
follows:  Left  anterior,  left  posterior,  right  anterior,  and 
right  posterior  (Fig.  78). 

The  technical  term  “position”  has  reference  to  the 
relation  the  presenting  part  bears  to  these  four  quadrants 

169 


170 


PRESENTATIONS  AND  POSITIONS 


of  the  mother’s  pelvis — for  example,  if  the  occiput  oc- 
cupies the  left  anterior  portion  of  the  mother’s  pelvis, 
we  speak  of  an  occipito  left  anterior  position— O.  L.  A. 


We  choose  arbitrarily  a prominent  point  in  the  pre- 
senting part  from  which  to  determine  the  relation  of  the 
presenting  part  to  the  four  quadrants  of  the  pelvis. 


PRESENTATIONS  AND  POSITIONS 


171 


This  point  is  called  the  “point  of  direction.”  In  vertex 
presentations  the  point  of  direction  is  the  occiput;  in 
breech  presentations,  the  sacrum;  in  face  presentations, 
the  chin;  in  shoulder  presentations,  the  scapula. 

When  a doctor  seeks  to  determine  the  presentation 
and  position,  he  must  find  out  what  part  of  the  fetus  is 
presenting  and  then  what  relation  the  point  of  direction 
bears  to  the  pelvis,  which  gives  him  the  position. 


Sacro  left  anterior. 


Sacro  right  posterior. 


Fig.  80. — Two  of  the  positions  of  breech  presentation. 


The  most  common  presentations  are  vertex  (often 
called  occipital),  breech,  face,  shoulder,  and  brow.  In 
breech  cases  the  feet  may  be  doubled  under  the  child, 
as  a tailor  sits  on  a bench;  the  feet,  one  or  both,  may 
fall  down  and  be  visible  at  the  vulva  (single  or  double 
footling);  the  knee  may  come  down,  or,  curiously,  the 
legs  may  be  extended  upward  along  the  chest  so  that  the 
toes  are  against  the  face.  These  last  are  difficult  cases, 
although  most  often  breech  deliveries  are  spontaneous. 

In  each  of  these  presentations  we  have  four  or  more 
positions:  for  the  occiput,  left  occipito-anterior,  O.  L.  A.; 


72 


PRESENTATIONS  AND  POSITIONS 


right  occipito-anterior,  0.  D.  A.;  right  occipito-posterior, 
0.  T).  P.;  and  left  occipito-posterior,  O.  L.  P.  (Fig.  79). 


Mento  right  posterior.  Mento  left  anterior. 

Fig:  81. — Two  of  the  positions  of  face  presentation. 

The  abbreviations  are  those  of  the  Latin  terms  used  for 
these  positions. 


Scapula  left  anterior.  Scapula  right  posterior. 

Fig.  82. — Two  of  the  positions  of  shoulder  presentation. 

For  the  breech,  the  sacrum  is  the  point  of  direction, 
and  we  have  the  sacro  left  anterior,  sacro  right  posterior, 
etc.  (Fig.  80).  For  the  face,  the  chin  is  the  point  of 


DIAGNOSIS  OF  PRESENTATION  AND  POSITION  1 73 


direction,  and  we  speak  of  mento  left  anterior,  mento 
right  posterior,  etc.  (Fig.  81).  In  shoulder  presentations 
we  have  scapula  left  anterior,  scapula  right  posterior,  etc. 
(Fig.  82). 

The  Diagnosis  of  Presentation  and  Position. 

It  is  often  desirable  that  the  nurse  be  able  to  tell  whether 
or  not  the  presentation  is  normal.  Particularly  is  this 


> 

o 


Fig.  83. — Is  the  ovoid  longitudinal  or  transverse? 

true  in  country  practice.  With  a little  experience  the 
nurse  will  learn  how  to  determine  the  position  of  the 
child  in  the  uterus  in  most  cases.  There  are  four  prin- 
ciples in  this  diagnosis  which  may  be  put  in  the  form  of 
questions : 

1.  Is  the  uterine  ovoid  longitudinal  or  transverse?  (Fig. 
83).  If  longitudinal,  the  child  lies  in  either  head  or 


1 74 


PRESENTATIONS  AND  POSITIONS 


breech  presentation.  The  nurse  lays  her  hands  along 
the  flanks  of  the  patient,  and  brings  the  large  uterus 
between  them.  If  the  greatest  diameter  lies  parallel 
with  the  mother,  the  uterine  ovoid  is  longitudinal. 

2.  What  is  over  the  inlet?  (Fig.  84).  The  nurse  places 
the  hands  over  the  lower  abdomen  and  presses  inward 


Fig.  84. — What  is  over  the  inlet? 


with  the  finger-tips  until  she  feels  the  lower  pole  of  the 
child.  If  this  is  hard  and  round,  it  is  the  head;  if  soft 
and  irregular,  the  breech. 

3.  What  is  in  the  fundus?  (Fig.  85).  The  hands  are 
placed  in  a corresponding  position  on  the  top  of  the 
uterus,  and  the  same  points  noted. 

4.  Where  is  the  hack?  One  hand  is  placed  on  each  side 


DIAGNOSIS  OF  PRESENTATION  AND  POSITION  1 75 


of  the  uterus  and,  pressing  inward  with  them  alter- 
nately, the  nurse  determines  which  side  is  more  resistant. 
The  more  resistant  side  represents  the  back. 

With  these  points  of  information  one  can  usually  con- 
struct the  diagnosis.  For  example,  if  the  ovoid  is  longi- 
tudinal, the  head  over  the  inlet,  the  breech  in  the  fundus, 
and  the  back  on  the  left  side,  the  case  is  one  of  occipito 
left  anterior  or  posterior.  There  are  many  finer  points 


Fig.  85. — What  is  in  the  fundus? 


in  this  method  of  diagnosis  which  the  physician  practices, 
but  which  cannot  be  gone  into  here. 

Of  all  the  presentations,  the  occipital  is  the  most 
favorable  for  mother  and  child,  and  of  the  four  positions 
of  the  occiput,  O.  L.  A.  is  the  best.  Fortunately,  this  is 
the  one  most  commonly  met  in  practice. 

The  nurse  is  aware  that  the  head,  in  order  to  pass 
through  the  pelvic  canal,  must  rotate  horizontally  on  the 


76 


PRESENTATIONS  AND  POSITIONS 


neck,  so  as  to  bring  its  long  axis  to  correspond  with  the 
anteroposterior  diameter  of  the  outlet.  If  the  occiput  is 
in  the  left  anterior  quadrant  of  the  pelvis,  it  has  only  to 
rotate  a small  part  of  a circle  to  get  in  front;  but  if  the 
occiput  be  in  the  right  or  left  posterior  quadrant  of  the 


Fig.  86. — Wiegand-Martin  method  of  delivering  the  after-coming  head  by 
flexion  through  seizure  of  lower  jaw,  and  extrusion  by  means  of  pressure  in  axis 
of  brim. 


pelvis,  it  has  to  rotate  nearly  half  a circle  to  get  in  front 
under  the  pubis.  This  rotation  takes  a long  time,  is 
painful  and  tedious,  so  that  sometimes  the  patient’s 
strength  gives  out  before  it  is  accomplished.  Then  the 
doctor  must  aid  her  with  the  resources  of  art.  These 
are  called  “posterior  positions,”  and  the  accoucheur 


DIAGNOSIS  OF  PRESENTATION  AND  POSITION  1 77 


usually  prefers  not  to  meet  them.  On  page  262  is  a 
description  of  labor  in  occipital  presentation. 

Breech  Cases.  -The  mechanism  of  breech  deliveries 
is  this:  under  strong  pains  the  breech  comes  through  the 
vulva  and  rises  up  toward  the  pubis,  the  accoucheur 
simply  receiving  the  child  as  it  appears.  The  legs  now 
drop  out  as  the  child  emerges;  the  patient  bears  down 
strongly,  and  the  shoulders  are  delivered,  after  which, 
unless  there  is  some  abnormal  delay,  the  head  comes 
with  the  face  over  the  perineum. 

Should  there  be  any  delay  in  the  delivery  of  the  shoul- 
ders, the  patient  is  exhorted  to  bear  down,  and  an  assist- 
ant, the  nurse  or  the  husband,  makes  steady  pressure 
over  the  top  of  the  uterus,  thus  forcing  the  child  down. 
If  this  is  not  successful,  the  doctor  delivers  the  arms 
gently,  then  inserts  the  fingers  into  the  infant’s  mouth, 
and,  with  the  other  hand  over  the  fundus  of  the  uterus, 
carefully  and  slowly  brings  the  face  over  the  perineum, 
after  which  the  occiput  comes  from  behind  the  pubis 
(Fig.  86). 

Shoulder  or  Transverse  Presentation. — When  the 
child  presents  other  than  longitudinally  we  speak  of 
transverse  presentation.  The  laity  call  it  a “cross  birth,” 
and  it  is  a serious  accident,  for,  unless  the  infant  can  be 
turned  so  that  its  long  axis  corresponds  with  the  long 
axis  of  the  mother,  either  one  or  both  of  the  lives  will 
be  lost.  As  soon  as  such  an  unusual  condition  is  dis- 
covered the  accoucheur  will  turn  the  child  into  a more 
favorable  presentation.  This  operation  is  called  version. 

12 


CHAPTER  V 


OBSTETRIC  OPERATIONS 

The  frequency  of  obstetric  operations  in  some  locali- 
ties is  out  of  proportion  to  the  actual  demands.  The 
practitioner,  trusting  to  the  safety  promised  by  the  new 
aseptic  and  antiseptic  technic,  attempts  and  performs 
many  operations  which  in  former  years  were  considered 
dangerous  and  were  employed  only  in  extreme  condi- 
tions. As  a result  of  this  the  mortality  of  child-bearing 
women  has  not  decreased  as  much  as  it  should  have  done 
by  grace  of  sterile  operating.  Those  men  who  have 
command  of  a good  aseptic  technic  are  the  ones  that 
appreciate  the  dangers  of  all  operations  and  the  safety  of 
leaving  the  case  to  nature,  while  those  men  who  cannot 
practice  asepsis  properly  are  the  ones  that  are  bold  in 
operating,  basing  their  confidence  on  the  success  ob- 
tained by  their  skilful  and  more  conservative  confreres. 

The  general  practitioner  will  attempt  obstetric  opera- 
tions of  the  gravity  of  capital  laparotomies  when  he 
would  not  think  of  performing  the  latter  himself,  but 
would  send  the  patient  to  a skilled  abdominal  surgeon. 
The  idea  of  a specialist  in  obstetrics  is  fast  gaining 
ground  among  the  better  educated  classes,  and  they  are 
demanding  a higher  standard  of  obstetric  work  from 
their  doctor,  and,  when  this  demand  is  unsatisfied,  are 
seeking  the  accoucheur  who  devotes  his  time  and  efforts 
to  this  particular  work. 

The  general  mortality  of  eclampsia  is  33  per  cent. ; of 
placenta  praevia,  15  per  cent. ; of  rupture  of  the  uterus,  60 
per  cent.,  and  yet  inexperienced  practitioners  will  under- 
178 


OBSTETRIC  OPERATIONS 


179 


take  the  care  of  these  cases  unconcernedly,  while  if  the 
patient  had  appendicitis  the  best  surgeon  obtainable 
would  be  called,  although  the  mortality  from  appen- 
dicitis is  seldom  more  than  10  per  cent.,  and  in  some 
hands  only  3 per  cent. 

The  child-bearing  woman  is  neglected,  both  in  regard 
to  her  medical  attendance  and  her  nursing,  and  it  is 
largely  her  own  fault.  She  does  not  demand  the  highest 
obstetric  skill  in  her  accoucheur,  nor  does  she  always 
pick  out  the  best  obstetric  nurse  obtainable.  While  for 
a surgical  or  gynecologic  operation  or  for  a medical  con- 
sultation all  considerations  are  brushed  aside  and  the  best 
man  selected,  for  a confinement  some  “old  friend  of  the 
family,”  or  “a  married  man,”  or  “one  who  does  not 
make  so  many  preparations,”  or  “one  who  does  not  charge 
so  much,”  is  selected,  the  patient  entirely  forgetting  that 
conditions  may  arise  that  will  suddenly  throw  her  into 
unprepared,  unskilful  hands,  where,  to  save  her  infant’s 
or  her  own  life,  the  most  rapid,  dextrous  operating  may 
be  necessary. 

For  her  nurse,  some  “monthly”  nurse  or  a “woman 
that  has  nursed  many  cases”  is  often  chosen,  and  in  the 
emergency  which  so  often  arises  the  unwise  mother  or 
the  innocent  babe  is  the  sufferer. 

Lack  of  space  prevents  going  further  into  this  vitally 
important  subject,  but  these  propositions  may  be  easily 
defended  by  reference  to  the  state  mortality  records  and 
case-books  of  the  gynecologists. 

1.  Except  in  women  of  perfect  health,  labor  is  not  a 
physiologic  process,  and  is  always  beset  with  dangers  of 
no  little  gravity  to  both  mother  and  infant. 

2.  The  importance  of  a labor  is  minimized  by  the 
public  and  also  by  the  general  practitioner,  and  to  a 
much  greater  extent  is  the  seriousness  of  the  obstetric 
complications  underrated. 


i8o 


OBSTETRIC  OPERATIONS 


3.  The  practice  of  obstetrics  requires  the  highest  kind 
of  surgical  skill,  a complete  and  consistent  technic,  a 
special  and  extended  experience  in  normal  and  patho- 
logic labors,  a clear  head,  unbefogged  by  alcoholics,  a 
steady  hand — not  one  trembling  from  use  of  tobacco 
or  other  drugs — a brave  and  courageous  spirit,  one  that, 
seeing  danger,  steps  boldly  in  to  rescue  one  or  both  lives 
from  peril,  and  a sympathetic  heart,  yet  one  strong 
enough  to  allow  the  mother  to  suffer  pain  when  it  is  for 
her  good.  Added  to  these  must  be  the  willing  sacrifice 
of  the  personal  comfort  and  convenience  which  obstetric 
work  so  often  demands. 

The  public,  by  honoring  the  obstetrician  and  remuner- 
ating him  properly  for  his  arduous  labors,  will  draw  to 
this  specialty  the  best  minds  and  the  most  skilful  hands, 
and  thus  serve  its  own  interests  better  than  it  is  now 
doing.  There  should  be  at  least  one  obstetric  specialist 
in  every  community.  These  remarks  apply  with  equal 
force  to  the  nursing. 

Preparation  for  Operation.  —The  general  rules  of 
surgical  nursing  apply  in  every  way  to  obstetric  cases. 
Everything  that  is  liable  to  come  in  contact  with  the 
patient  must  be  sterile.  It  is  not  true  that  the  strin- 
gent rules  of  asepsis  in  general  surgery  may  be  disre- 
garded in  obstetrics.  Therefore  the  nurse  will  need  no 
advice  to  prepare  sterile  towels,  sheets,  pledgets,  gauze, 
basins,  brushes,  hot  and  cold  sterile  water,  etc.  All 
these  things  the  obstetric,  as  well  as  the  general,  sur- 
geon needs. 

Obstetric  operating  is  more  bloody  than  any  other,  and 
there  are  many  factors  which  make  it  the  most  mussy. 
Such  are  liquor  amnii,  meconium,  vemix  caseosa,  and 
sometimes  urine  of  the  baby,  the  bowel  movements  and 
urination  of  the  mother,  all  of  which  discharges  not 
seldom  take  place  during  the  delivery.  Aside  from  the 


PREPARATION  FOR  OPERATION 


181 


necessity  of  using  much  linen  and  many  pledgets,  there  is 
great  danger  of  infecting  the  mother  from  the  fecal 
matter.  Deaths  have  occurred  because  of  it. 

Further,  obstetric  operating  requires  more  exposure 
of  the  field  than  any  other,  and  the  patient  may  take 
cold.  Frequent  changes  of  the  position  or  attitude  of 
the  patient  may  be  required,  so  that  sterile  sheets  are 
thereby  disarranged.  The  nurse  must  see,  therefore, 
that  the  patient  is  not  too  much  exposed,  either  to  cold 
or  to  infection.  Obstetric  operations  are  not  the  de- 
liberate technics  of  the  surgeon,  but  often  necessarily 
rough  and  rapid,  and  with  the  exhibition  of  much  phys- 
ical strength.  The  nurse  must  not  lose  her  presence  of 
mind  and  imagine  the  patient  will  be  tom  to  pieces, 
though,  sadly  enough,  in  unskilled  hands,  such  may  be 
literally  true.  Properly,  a man  may  use  power  of  150 
pounds  and  not  injure  the  patient  or  the  baby.  Im- 
properly used,  10  pounds  may  do  damage. 

Obstetric  operating  is  full  of  surprises  and  acute  emer- 
gencies, therefore  the  nurse  must  keep  her  mind  focused 
on  the  doctor’s  work.  If  she  has  the  room,  tables,  sup- 
plies, etc.,  properly  prepared  and  arranged  things  will 
go  more  smoothly.  So  she  should,  as  a labor  pro- 
gresses, like  a general  during  the  battle,  frequently 
survey  the  field  to  assure  herself  that  everything  is  in 
readiness. 

If,  as  the  labor  goes  on,  the  possibility  of  an  operation 
is  considered,  the  nurse  should  provide  a suitable  oper- 
ating table.  Most  physicians,  unfortunately,  content 
themselves  with  putting  the  patient  across  the  bed. 
This  is  to  avoid  alarming  the  patient,  but  while  the  doctor 
may  spare  the  woman  a little  nervousness,  he  often  does 
her  and  her  babe  real  injury  and  is  unjust  to  himself. 
I know  that  both  women  and  babies  have  been  lost  be- 
cause the  physician  did  not  avail  himself  of  the  best 


OBSTE  ERIC  OPERA  TIONS 


182 


auxiliaries  obtainable  for  his  work.  It  goes  without 
saying  that  an  operation  can  be  better  performed  on  a 
proper  table  than  on  a low,  back-breaking  bed. 

The  physician  who  does  not  insist  on  the  best  possible 
conditions  in  which  to  work  is  unfair  and  unkind  to  the 
mother  and  babe,  and  unjust  to  his  art. 

The  accoucheur  should  have  plenty  of  assistants  for 
obstetric  operations.  A rational  mind  cannot  under- 
stand why  an  accoucheur,  when  fully  able  to  do  other- 


Fig.  87. — A room  in  a private  home  arranged  for  operation.  In  the  center  is 
the  kitchen  table  with  a Kelly  pad  made  of  newspapers,  and  covered  with  a 
sheet.  To  the  right  is  a euchre-table  carrying  a pile  of  sterile  towels,  a jar  of 
pledgets,  a bottle  of  sutures,  and  the  instrument  pan.  On  the  left  is  a sewing- 
table  with  one  bowl  of  1 per  cent,  lysol,  one  bowl  of  1 : 1000  bichlorid,  each  with 
pledgets,  a pitcher  of  fresh  hot  lysol  solution,  and  a saucer  containing  scissors 
and  tape  for  the  cord. 

wise,  should  work  short  handed  in  such  difficult  and 
serious  operations,  when  the  surgeon,  for  his  simplest 
operations,  has  an  anesthetizer,  at  least  one  other 
assistant,  and  one  or  sometimes  two  nurses.  This 
lack  of  assistants  throws  extra  work  on  the  nurse  and 
often  overtaxes  her  strength.  If  no  other  nurses  or 
physicians  are  obtainable,  the  nurse  should  call  some 
courageous  woman  to  hold  the  limbs  of  the  patient 
while  on  the  table.  The  husband  usually  cannot  be 
relied  on;  he  is  likely  to  faint. 


PREPARATION  OF  THE  ROOM 


183 


The  room  should  be  arranged  to  resemble  as  closely 
as  possible  the  operating  room  of  a lying-in  hospital, 
and  every  house  has  the  necessary  tables,  basins,  etc.,  so 
that  this  can  almost  always  be  done  if  the  will  is  there 
(Fig.  87).  The  instruments  vary  with  the  operation  to 
be  performed. 

Preparation  of  the  Room.  A kitchen  or  library 
table  makes  an  excellent  operating  table;  a sewing- table 


Fig.  88. — Diagram  of  room  arranged  for  operation. 


does  well  for  the  instruments  and  basins;  a euchre-table 
gives  additional  space.  Two  kitchen  chairs  with  a table 
board  on  them  make  an  excellent  side  table.  A blanket 
is  folded  so  as  to  make  a pad  to  put  under  the  patient; 
this  is  covered  with  newspapers.  A roll  of  newspapers 
is  shaped  like  a Kelly  pad,  covered  with  a rubber  sheet, 
or,  in  the  absence  of  this,  with  more  newspapers,  and 


184 


OBSTETRIC  OPERATIONS 


pinned  in  shape  with  large  safety-pins.  Over  all  is 
thrown  a clean  sheet.  Care  is  taken  to  protect  the  floor 
around  the  place  of  operation.  A rug  is  removed; 
carpet  is  covered  with  heavy  paper  or  a rubber  sheet. 
The  sewing-table  is  put  on  one  side  of  the  operator, 
within  easy  reach,  and  yet  far  enough  away  not  to  inter- 
fere with  his  motions.  It  holds  the  hand  solution  (with 
a brush  in  it) , the  basin  of  pledgets  lying  in  an  antiseptic 
solution  (to  wash  the  parts  with),  and  a saucer  with  a 
catheter,  scissors,  artery  clamp,  and  tape  for  tying  the 
cord  lying  in  lysol  solution.  The  other  table  stands  on 
the  other  side  in  a corresponding  position.  It  carries  the 
pan  of  boiled  instruments,  a pile  of  clean  or,  preferably, 
sterilized  towels,  a jar  of  sterile  pledgets,  and  the  suture 
material.  A kitchen  chair  is  placed  before  the  table  for 
the  operator  (Fig.  88). 

Not  far  away  the  nurse  places  a pillow  covered  with 
towels,  with  a tracheal  catheter  handy,  and  next  to  it  a 
bath-tub  with  hot  water.  These  preparations  are  for  the 
resuscitation  of  the  newborn  if  it  should  arrive  asphyxi- 
ated. The  hot- water  bag  is  wrapped  in  the  baby  receiver 
and  placed  on  the  pillow. 

The  sterile  douche-bag  is  gotten  in  readiness,  being 
hung  near  the  table,  and  the  solutions  in  the  basins  are 
replenished  and  warmed  by  the  addition  of  hot  water 
just  before  the  patient  is  placed  on  the  table.  Then  the 
nurse  assures  herself  that  she  has  a good  supply  of  hot 
and  cold  sterile  water. 

Preparation  of  the  Patient. — If  the  woman  comes 
to  operation  in  the  course  of  an  ordinary  labor,  she  is 
already  partly  prepared  and  needs  only  an  antiseptic 
washing  after  she  comes  on  the  table.  If  the  operation 
is  an  emergency,  the  patient  had  better  be  prepared  on 
the  table,  and  then  the  ordinary  surgical  method  is  here 
employed — shaving  carefully  the  hair,  scrubbing  with 


PREPARATION  OF  THE  PATIENT 


185 


soap  and  water,  with  bichlorid  1 : 1500,  or  lysol  1 per 
cent.,  or  both.  Some  operators  use  tincture  of  iodin. 
(See  p.  no.)  The  nurse  should  ask  the  accoucheur  if 
she  is  to  give  the  patient  a vaginal  douche  and  catheter- 
ize  her.  Most  operators  dispense  with  douches  nowa- 
days, and  catheterization  is  usually  done  after  the  pa- 
tient is  put  on  the  table. 


Fig.  89. — Patient  in  modified  lithotomy  position  for  operative  delivery. 

After  the  preparation,  sterile  leggings  are  put  on  and 
the  body  protected  by  a blanket  and  sterile  sheets.  The 
exact  position  a parturient  should  hold,  for  operative 
delivery  from  below,  is  shown  in  Fig.  89.  The  buttocks 
are  brought  3 inches  over  the  edge  of  the  table.  The 
Kelly  pad  should  have  no  sleeve,  nor  should  the  air- 


I 86  OBSTETRIC  OPERATIONS 

cushion  project  beyond  the  edge  of  the  table.  The  legs 
are  held  in  a modified  lithotomy  position  by  an  assistant, 
on  each  side,  with  one  hand  on  the  instep  of  the  foot 
and  the  other  at  the  knee.  If  there  is  a lack  of  assistants 
to  hold  the  legs,  the  patient  is  arranged  as  in  Fig.  90, 
with  a sheet  supporting  the  limbs. 

A large  square  sheet  is  rolled  together  on  the  bias, 
the  middle  placed  around  the  shoulders,  and  the  ends  are 


Fig.  90. — Lithotomy  position  with  limbs  supported  by  a sheet-sling. 

tied  securely  around  the  outside  of  the  limb  just  below 
the  knee.  After  the  knot  is  firmly  tied,  for  additional 
security  the  end  of  the  sheet  is  pinned.  The  sheet  should 
be  stretched  over  the  shoulder,  not  over  the  back  of  the 
neck.  The  nurse  must  remember  that  this  position  is 
very  fatiguing  to  the  patient,  even  under  an  anesthetic, 
and  the  limbs  should  be  stretched  out  occasionally  during 


LIGHT  AND  HEAT  I 87 

the  operation,  and  the  sheet  removed  at  the  first  oppor- 
tunity after  it. 

Preparation  of  Instruments.  The  physician  will 
usually  select  such  instruments  as  he  will  need  for  the 
particular  operation  to  be  performed,  but  the  nurse 
should  familiarize  herself  with  the  names  and  appearance 
of  those  commonly  used,  so  as  to  get  for  him  whatever 
asked.  The  instruments  should  be  boiled  in  a 1 per  cent, 
soda  or  a 1 per  cent,  borax  solution  for  at  least  five 
minutes  before  the  operation.  If  the  physician  carries 
a pan  in  his  satchel  for  this  purpose,  it  is  much  better 
than  if  the  nurse  has  to  use  the  wash-boiler,  fish-boiler, 
roasting-pan,  or  other  large  household  utensil.  In  gen- 
eral it  is  best  to  use  as  few  house  utensils  as  possible  in 
this  work.  Nickeled  instruments  tarnish  if  boiled  in 
water  without  an  alkali.  For  this  purpose  soda  bicar- 
bonate or  washing-soda  is  used,  1 dessertspoonful  to  1 
quart  of  water,  borax  in  the  same  proportion,  or  a little 
lysol.  Lists  of  the  instruments  needed  for  the  most  com- 
mon operations  will  be  found  with  the  descriptions  of 
these  operations. 

Light  and  Heat.  These  two  important  factors  must 
receive  adequate  attention.  In  the  daytime  the  opera- 
tive end  of  the  table  is  put  toward  the  window,  and  at 
night  toward  the  center  of  best  light.  In  country  prac- 
tice a sufficient  number  of  good  lamps,  filled  and  trimmed, 
should  be  at  hand. 

The  room  must  be  warmed,  as  the  patient  is  often 
much  exposed,  and  the  child  too  should  be  given  a 
warm  welcome.  When  the  operation  is  prolonged,  and 
in  abdominal  work,  a few  warm-water  bottles  should  be 
laid  alongside  the  chest  and  arms.  In  hospitals  the 
operating  table  may  be  provided  with  a hot-water  pan 
or  an  electric  heating  pad.  Both  must  be  watched  for 
overheating. 


OBSTETRIC  OPERATIONS 


l88 

The  bed  should  be  warmed  for  the  reception  of  the 
patient  after  the  delivery,  although  usually  there  is  not 
so  much  shock  following  obstetric  operations  as  follows 
severe  surgical  measures. 

Anesthesia.  —The  nurse  occasionally  has  to  admin- 
ister the  anesthetic,  but  she  should  always  have  it  under- 
stood that  the  physician  assumes  the  responsibility. 
It  is  best,  in  such  cases  (which,  in  the  writer’s  opinion, 
should  not  occur),  for  the  physician  to  put  the  patient 
to  sleep  and  let  the  nurse  continue  the  narcosis.  For 
operations  the  full  surgical  anesthesia  is  employed.  In 
justice  to  all  concerned,  an  anesthetizer  ought  to  be 
employed. 

The  face  should  be  smeared  with  vaselin  to  avoid  the 
unpleasant  burns  that  may  be  produced  by  chloroform, 
and  care  should  be  taken  that  none  of  the  latter  is 
dropped  into  the  eye. 

In  small  rooms,  where  gas  is  burning  and  chloroform 
is  used,  the  gas  decomposes  the  chloroform  and  irritating 
vapors  are  liberated.  These  vapors  are  more  active  in 
the  presence  of  steam,  and  they  are  poisonous  when 
concentrated.  Fatalities  have  been  reported.  Cough- 
ing and  sore  throat  are  the  milder  symptoms.  To  avoid 
these  evil  effects  the  nurse  will  provide  free  ventilation 
in  the  confinement  room. 

The  author  prefers  ether  as  an  anesthetic.  While  the 
danger  of  explosion  from  an  open  flame  is  present,  or- 
dinary care  will  obviate  it.  The  mask  and  bottle  should 
not  be  within  8 feet  of  the  grate  or  less  than  3 feet  from 
the  gas  jet.  Ether  vapor  is  heavy  and  sinks  to  the  floor. 

Care  After  Operations.— After  the  delivery  the 
physician  has  usually  cleansed  the  vulva  of  blood,  but 
he  leaves  the  nurse  to  clean  the  nates  and  limbs.  This 
she  does  with  a towel  wet  with  warm  solution,  taking 
extreme  care  not  to  approach  the  perineum  with  the 


CARE  OF  THE  CLILD  1 89 

cloth  or  disturb  any  packing  that  might  have  been 
inserted. 

The  abdominal  binder  with  T,  holding  the  vulvar  dress- 
ing, is  now  snugly  applied,  after  which  the  patient  is 
removed  to  her  bed.  Great  care  and  gentleness  are  re- 
quired during  this  procedure  so  as  not  to  jar  the  woman, 
and  the  head  must  be  held  low,  so  that  fainting  is  pre- 
vented. The  nurse  now  has  to  rearrange  the  room  while 
the  physician  or  his  assistant  watches  the  patient  and  the 
infant;  she  cannot  do  all  three.  Bloody  pads,  pledgets, 
and  the  placenta  (the  last  only  after  the  physician  has 
inspected  it)  are  wrapped  in  newspapers  and  sent  out  to 
be  burned.  Bloody  towels  and  sheets  are  thoroughly 
rinsed  in  cold  water  and  wrung  dry  before  being  sent  to 
the  laundry. 

The  instruments  are  thoroughly  washed  in  cold  water 
and  scrubbed  with  a brush,  especial  care  being  given  the 
locks,  hinges,  and  corrugations.  Then  the  darkened 
spots  are  scoured  with  damp  Hand  Sapolio,  the  instru- 
ments then  scalded,  and  dried  out  of  a hot  lysol  solution; 
being  hot,  they  dry  quickly  and  do  not  rust.  After 
septic  operations  the  instruments  should  be  boiled  in 
an  alkaline  solution  before  being  put  away. 

Care  of  the  Child.  -After  operative  delivery  the 
child  requires  special  guarding,  as  it  is  likely  to  choke 
up  with  mucus,  or  it  may  become  cyanotic  because  its 
lungs,  not  having  been  fully  unfolded  (atelectasis),  do 
not  present  enough  air  surface  for  oxygenation  of  the 
blood.  If  the  infant  is  troubled  with  mucus,  this  should 
be  removed  by  the  little  finger  covered  with  a soft  linen 
cloth.  Then  the  child  should  be  placed  on  its  side, 
with  the  head  lower  than  the  chest;  the  mucus  thus 
escapes  from  the  side  of  the  mouth.  A little  water  may 
be  given.  It  carries  the  mucus  down  with  the  swallow- 
ing action. 


190 


OBSTETRIC  OPERATIONS 


Should  the  infant  turn  blue,  the  case  is  serious  and  the 
physician  should  be  notified.  While  he  is  coming  the 
child  may  die,  so  the  nurse  must  do  something  to  save 
it.  (See  chapter  on  Asphyxia  Neonatorum.) 

The  nurse  may  glance  at  the  navel  to  see  if  it  is 
securely  ligated,  and  that  there  is  no  hemorrhage  from  it. 
If  the  head  of  the  babe  has  been  injured  by  the  forceps, 
great  care  is  required  to  prevent  infection.  In  the 
absence  of  instructions  from  the  physician  the  little 
wounds  are  washed  with  1 : 2000  bichlorid  solution,  dried, 
and  dressed  with  sterile  gauze  sewed  on  the  head  like  a 
cap.  The  physician’s  attention  should  be  directed  to 
these  and  other  unusual  conditions  of  the  newborn.  It 
is  important  that  a child  delivered  by  an  operative  pro- 
cedure be  kept  specially  warm,  as  it  suffers  shock.  This 
is  a fact  not  sufficiently  appreciated. 

Care  of  the  Mother. — The  usual  attention  given 
the  mother  after  labor  will  suffice  here  unless  the  opera- 
tion has  been  very  difficult,  with  lacerations  of  the  soft 
parts,  or  of  a special  nature,  as  symphysiotomy  or 
cesarean  section.  The  bed  should  be  warmed,  the 
uterus  watched  carefully  for  relaxation  and  hemorrhage; 
the  room  should  be  aired  and  darkened. 

After-treatment  of  special  operations  will  follow  the 
description  of  same. 

MAJOR  OPERATIONS 

The  Forceps.  The  most  common  operation  is  the 
application  of  forceps.  When  the  woman  has  labored 
hard  and  long,  and  in  spite  of  her  best  efforts  cannot  de- 
liver the  head  through  the  pelvis,  the  physician  lends  her 
aid  by  means  of  the  forceps.  This  instrument  should 
never  be  applied  until  the  woman  has  proved  her  inability 
to  deliver  the  infant  or  to  deliver  it  quickly  enough  for  its 
safety  or  her  own.  The  baby  may  be  a little  larger  than 


MAJOR  OPERATIONS 


l9l 

usual,  or  the  parts  not  so  elastic  and  dilatable  as  neces- 
sary, or  the  nervous  system  may  prove  unequal  to  the 
strain  of  labor.  This  last  is  more  common  in  the  deli- 
cately bred  woman. 


Fig.  91. — Simpson’s  forceps. 


The  instrument  was  invented  by  a member  of  the 
Chamberlen  family  in  1683,  and  was  held  for  many  years 
as  a secret.  It  consists  of  two  blades  which  are  applied 
separately  to  the  sides  of  the  head  and  locked.  By 
traction  on  the  handles  the  head  is  delivered,  the  body 


Fig.  92. — Tarnier’s  axis-traction  forceps.  Below  is  one  of  the  traction  rods. 

following  (Fig.  91).  Unless  properly  applied  and 
manipulated  the  instrument  may  do  great  injury  to 
the  mother’s  organs,  and  also  damage  the  child  more 
or  less  permanently. 

The  axis-traction  forceps  (Fig.  92)  is  larger  than 
the  Simpson,  the  type  of  ordinary  forceps.  The  axis- 


192 


OBSTETRIC  ORE  RATIONS 


Fig.  93. — Delivery  of  the  head,  after  episiocomy.  (A  photograph.) 


Fig.  93a. — Head  just  delivered.  (A  photograph.) 


Fig.  94. — Delivery  of  anterior  shoulder.  Nurse  holds  ready  swab  for  wiping 
out  baby’s  mouth.  (A  photograph.) 


Fig.  94a. — Delivery  of  posterior  shoulder.  (A  photograph.) 


INSTRUMENTS  FOR  FORCEPS  OPERATION  1 93 


traction  instrument  is  used  when  the  head  is  high  up, 
therefore  the  operation  is  often  called  the  high  forceps 
operation.  This  latter  is  attended  with  a higher  mor- 
tality for  the  mother  and  infant.  It  is  very  bloody,  and 
nearly  always  the  mother’s  tissues  suffer  severe  injury. 
The  baby  is  also  frequently  marked.  Later  it  may  die 
of  hemorrhage  in  the  brain. 


List  of  Instruments  for  Forceps  Operation 

Obstetric  forceps,  ordinary  or  axis-traction,  as  ordered. 
Two  long  artery  forceps. 

Four  short  artery  forceps. 

Two  vulsellum  forceps.  (See  Fig.  96.) 

Two  tissue  forceps. 

Three  scissors  (one  long). 

Two  needle-holders,  six  needles. 

Two  large  perineal  retractors,  or  specula. 

One  long  uterine  packing  forceps.  (See  Fig.  hi.) 
One  uterine  douche-tube. 

Suture  material:  silkworm-gut  or  catgut,  as  ordered. 
(See  chapter  on  Sterilization  of  Supplies.) 

One  catheter  (soft  rubber). 

Stethoscope. 

Salt  solution  needle. 

Two  tracheal  catheters  for  aspirating  mucus  from 
trachea;  these  must  not  be  boiled. 

The  supplies,  as  sheets,  towels,  gowns,  sponges,  basins, 
pitchers,  etc.,  required  are  identical  with  those  needed 
for  normal  labor. 

Duties  of  Nurse  During  Forceps  Operation. 

The  nurse,  having  prepared  everything  as  described,  and 
having  enough  help,  will  only  need  to  wait  on  the 
operator,  handing  him  such  things  as  he  needs.  She 
need  not  have  absolutely  sterile  hands — in  fact,  had 

13 


194 


OBS  TE  TRIG  OPERA  TIONS 


better  not  be  expected  to  touch  aseptic  things.  When 
necessary  to  replenish  basins,  she  should  touch  only  the 


outside;  when  necessary  to  supply  sponges,  she  carries 
them  with  a sterile  dressing  forceps.  For  this  purpose 


THE  WALCHER  POSITION 


195 


she  provides  a tall,  wide-mouthed  jar,  with  a 1 per  cent, 
lysol  solution,  in  which  the  forceps  stand  when  not  in 
use.  (See  Fig.  219,  page  446.)  It  is  remarkable  what 
dexterity  a nurse  acquires  in  handling  sterile  towels, 
pledgets,  etc.,  with  the  long  dressing  forceps. 

When  the  child  is  born,  she  washes  the  eyes  with 
boric  solution,  as  directed  under  Normal  Labor.  Now 
she  may  have  to  grasp  the  uterus.  The  duties  resemble 
much  those  required  at  a normal  confinement. 

During  difficult  high  forceps  deliveries,  and  also  when 
in  breech  deliveries  the  after-coming  head  gives  trouble 


Fig.  96. — Vulsellum  forceps  with  teeth  protected  to  prevent  injury  to  rubber 
gloves  while  operating. 


in  passing  through  the  pelvis,  the  patient  is  sometimes 
ordered  put  in  the  Walcher  position  (Fig.  97). 

The  Walcher  Position.  ^This  attitude  of  the 
patient  cannot  be  held  long,  as  it  is  very  fatiguing.  The 
nurse  allows  the  legs  to  fall  very  slowly  and  gently  toward 
the  floor,  until  they  rest  in  the  position  shown  in  Fig.  97.1 
The  sacrum  must  rest  just  on  the  end  of  the  table, 
which  is  protected  by  a soft  blanket;  the  back  arches  up, 
as  can  be  seen  in  the  illustration;  the  shoulders  rest  on 

1 This  figure  and  many  of  the  others  were  photographed  from  a 
model  by  the  author.  The  woman  was  attired  in  a closely  fitting  union 
suit,  and  great  attention  was  paid  to  the  finest  details,  so  as  to  get  a 
scientifically  correct  picture. 


OBSTETRIC  OPERATIONS 


196 

the  table.  The  legs  are  held  securely,  so  that  the  patient 
does  not  slide  off  the  table.  As  soon  as  the  head  is  well 
down  in  the  pelvis,  the  legs  are  put  back  into  the  pose 
they  have  in  Fig.  89. 


Fig.  97. — The  Walcher  position. 


Breech  Extraction.  In  some  breech  labors,  in 
spite  of  powerful  pains,  the  breech  will  not  come  down, 
and  the  doctor  finds  it  necessary  to  help  nature  deliver 
the  child.  As  in  forceps  cases,  the  child  may  be  a little 
too  large,  or  the  maternal  parts  a little  too  small  or  too 
rigid. 


DECAPITATION 


97 


The  accoucheur,  after  the  same  preparations  as  for 
any  major  operation,  folds  the  hand  into  a narrow  cone, 
inserts  it  into  the  uterus,  grasps  a foot,  and  gently 
draws  this  down  into  the  vulva.  Now,  by  steady  trac- 
tion, the  infant  is  drawn  out,  first  by  one  foot,  then  by 
the  leg,  then  the  thigh,  then  aided  by  drawing  on  the 
other  leg,  proceeding  carefully.  The  shoulders  some- 
times cause  great  difficulty,  and  the  operator  throughout 
has  a great  task  to  avoid  fracturing  the  bones.  When  the 
head  is  to  come,  two  fingers  are  inserted  into  the  child’s 
mouth;  the  other  hand  is  over  the  nape  of  the  neck,  and, 
aided  by  an  assistant  pressing  from  the  outside  over  the 
uterus,  the  head  is  delivered. 

The  instruments  necessary  for  breech  extraction  are 
the  same  as  those  for  forceps  operation,  as  it  is  sometimes 
necessary  to  apply  the  forceps  to  the  after-coming  head, 
and  frequently  lacerations  are  to  be  repaired. 

Version. — This  means  turning  the  child  from  an  un- 
favorable presentation  to  a favorable  or  normal  presenta- 
tion. In  practice  we  have  most  commonly  version  from 
a shoulder  presentation  to  a breech  presentation.  The 
operation  is  often  difficult  and  laborious,  and  sometimes 
very  dangerous.  The  child  is  often  lost  by  the  untimely 
detachment  of  the  placenta,  and  the  uterus  is  sometimes 
ruptured  in  the  effort  to  turn  the  child.  Rupture  of  the 
uterus  is  a sad  accident,  as  even  with  the  best  treatment 
over  60  per  cent,  of  the  mothers  and  98  per  cent,  of  the 
children  die.  The  preparations  for  version  are  the  same 
as  for  the  forceps  operation,  and  to  the  instruments 
should  be  added  two  version  slings.  These  are  of  §-inch 
tape  and  each  1 yard  long;  they  are  applied  around  the 
leg  or  arm  which  has  been  delivered,  so  as  to  aid  subse- 
quent extraction. 

Decapitation. — When  a labor  in  which  the  child 
presents  transversely,  that  is,  a “cross-birth,”  is  allowed 


98 


OBSTETRIC  OPERATIONS 


to  go  on  and  has  become  neglected,  the  child  is  found 
wedged  into  the  pelvis  so  that  it  cannot  be  turned  nor 
straightened  out  so  as  to  be  extracted  lengthwise.  These 
cases  are  called  “neglected  transverse  presentations,”  and 
are  very  formidable.  In  such  emergencies  the  accoucheur 
is  compelled  to  cut  the  child  into  two  parts  and  deliver 
each  separately.  The  section  is  usually  made  at  the 


Fig.  98. — Braun’s  decapitation  hook. 

neck,  but  sometimes  the  trunk  is  divided.  The  neck  is 
divided  by  means  of  strong  scissors  or  a blunt  hook  in- 
vented by  Carl  Braun  (Fig.  98).  It  is  a horrible  oper- 
ation, and  fortunately  rare. 

Craniotomy. — This  is  another  of  the  mutilating 
operations  on  the  fetus,  and  consists  of  opening  the  skull 
of  the  infant  with  sharp  scissors  or  a long  trephine, 


evacuating  the  brain  matter,  then  crushing  the  bones 
together  so  as  to  reduce  the  size  of  the  head,  and  extract- 
ing it  after  this  reduction  in  size.  Fig.  99  shows  the 
crushing  instrument;  Fig.  100,  a common  form  of  per- 
forator. Embryotomy  is  a term  used  to  designate  all 
the  mutilating  operations  on  the  child.  Cranioclasis 
means  the  crushing  of  the  child’s  head,  and  cephalo-tripsy 
the  same,  but  without  opening  the  skull.  When  per- 


CRANIOTOMY 


I99 


formed  on  a child  already  dead  these  operations  are 
disagreeable  enough,  but  when  the  obstetrician  is  called 
upon  to  sacrifice  the  child’s  life  by  them,  truly  they 
require  moral  courage.  Yet  conditions  arise  in  which 
the  accoucheur  stands  before  dreadful  alternatives— 
to  try  to  save  the  infant  will  almost  surely  lead  to  the 
mother’s  death;  to  sacrifice  the  infant  will  almost  surely 
save  the  mother.  The  question  is  a difficult  one;  it  is 
delicate,  it  is  serious,  because  both  lives  usually  hang  in 
the  balance  either  way,  and  many  considerations  not 
medical  in  their  nature,  such  as  religion  and  social  status, 
enter  into  it.  At  no  place  in  all  medicine  and  surgery 
does  the  physician  meet  a more  heart-felt,  perplexing,  and 
weighty  question. 


Fig.  100. — Smellie’s  perforating  scissors. 


The  conditions  which  usually  lead  to  this  difficulty  are 
those  of  mechanical  disproportion  between  the  baby  and 
the  maternal  parts.  The  baby  is  too  large  or  the  parts 
(pelvis  or  soft  passages)  are  too  small  to  allow  a natural 
delivery.  If  the  patient  cannot  deliver  herself,  and  if 
labor  cannot  be  accomplished  by  forceps  or  by  extrac- 
tion by  the  breech,  the  questions  arise,  Shall  we  reduce 
the  bulk  of  the  infant,  or  shall  we  remove  the  child  by  a 
new  passage  (cesarean  section),  or  shall  we  enlarge  the 
pelvis  (symphysiotomy)  ? 

The  last  two  operations  are  quite  safe  if  performed 
very  early  in  labor,  before  the  patient  is  infected  or  ex- 
hausted. If  performed  late,  when  either  infection  or 
exhaustion  is  present,  the  mortality  is  very  high,  while 
the  craniotomy  has  hardly  any  mortality.  If  the  child 


200 


OBSTETRIC  OPERATIONS 


is  dead,  the  question  is  simple,  but  if  it  is  alive,  the  de- 
cision is  extremely  difficult,  and  requires  the  highest  kind 
of  obstetric  judgment. 

The  author’s  practice  is  this : If  the  woman  is  in  prime 
condition — that  is,  if  she  is  not  infected,  her  earlier 
attendants  having  been  aseptic,  and  if  she  has  not  been 
in  labor  long  and  no  attempts  at  operative  delivery  have 
been  made — he  strongly  counsels  removal  to  a good  hos- 
pital and  the  performance  of  cesarean  section  or  pubiot- 
omy.  If  the  conditions  are  not  favorable  for  a success- 
ful abdominal  delivery  or  opening  of  the  pelvis,  he  ad- 
vises the  sacrifice  of  this  child,  and  the  performance  of 
cesarean  section  or  premature  delivery  in  the  next 
pregnancy. 

Unfortunately,  most  labors  are  conducted  in  a blind 
manner,  and  the  difficulty  is  not  recognized  until  opera- 
tive attempts,  sometimes  to  the  number  of  fifteen,  have 
been  made  and  proved  fruitless.  Then  only  is  special 
skill  called  in,  and  in  such  forlorn  cases  one  is  to  be  con- 
gratulated if  the  mother  can  be  brought  through  alive, 
even  though  not  whole. 

Early  recognition  of  impending  difficulties  will  avoid 
most  of  them,  and  this  is  the  reason  why  specially 
skilled  attendants  should  be  employed  for  all  obstetric 
cases. 

Preparation  for  the  Mutilating  Operations. 

The  nurse  will  prepare  for  craniotomy,  decapitation,  and 
the  other  operations  of  this  class  as  for  any  major 
obstetric  operation.  The  instruments  are  shown  in  Fig. 
ioi.  After  the  child  is  delivered  the  head  should  be 
reshaped  by  filling  it  with  cotton  and  sewing  up  the 
injured  skin.  The  feelings  of  the  family  should  be 
spared  as  much  as  possible. 

Baptism.  —If  the  family  is  Catholic,  the  nurse,  unless 
the  physician  has  attended  to  the  matter,  should  arrange 


CE SATE AN  SECTION 


201 


for  the  baptism  of  the  child  when  the  possibility  presents 
that  it  will  die.  The  physician  may  give  the  child 
intra-uterine  baptism. 

Even  a non- Catholic  may  administer  these  rites,  and 
the  nurse  will  do  much  for  the  mental  comfort  of  her 
patient  if  she  sees  that  her  religious  beliefs  are  con- 
formed with. 


Fig.  ioi. — Instruments  for  embryotomy. 


Cesarean  Section.  -This  operation  does  not  take  its 
name  from  Caesar,  but  from  a Latin  word,  cedere , mean- 
ing to  cut.  There  is  no  evidence  that  Caesar  was  deliv- 
ered by  this  means.  The  first  authentic  cesarean  section 
on  the  living  was  performed  about  three  hundred  years 
ago  by  a swine-gelder  on  his  own  wife.  Thirteen  mid- 
wives and  barbers  had  exhausted  their  skill  on  the  poor 
woman.  She  recovered!  The  scene  of  a modern  cesa- 


202 


OBSTETRIC  ORE RAT/OIVS 


rean  section  differs  from  that  of  one  given  by  Mercurio  in 
Italy  in  1595  (Fig.  102). 

Delivery  by  the  abdominal  route  is  performed  when 
the  maternal  passages  are  so  obstructed — as  by  con- 


Fig.  102. — A cesarean  section  in  Italy  in  the  sixteenth  century  (Witkowski). 


tracted  pelvis  or  scars  in  the  soft  parts,  or  by  tumors, 
such  as  fibroids,  wedged  in  the  pelvis — that  the  child  has 
no  room  to  pass.  Sometimes  there  is  room  enough  for 
a child  that  is  reduced  in  size  by  mutilation  to  pass 


CESAREAN  SECTION 


203 


through,  but  not  for  a living  child.  In  these  cases  the 
physician  may  do  the  abdominal  delivery  to  save  the 
child. 

The  operation  consists  of  seven  steps:  (1)  Opening 
the  abdomen;  (2)  incision  in  the  uterus;  (3)  removal  of 
the  child;  (4)  removal  of  the  placenta  and  secundines; 
(5)  careful  suture  of  the  uterus;  (6)  peritoneal  toilet; 
(7)  suture  of  the  abdominal  wall.  Sometimes  the  uterus 
is  removed  also.  This  is  called  a Porro  operation. 

Ordinarily,  cesarean  section  is  not  a hard  operation, 
and  performed  in  a good  hospital,  at  an  early  period  of 
labor,  it  is  not  very  dangerous,  the  mortality  being  about 
3 per  cent,  in  the  most  favorable  cases  and  in  skilful 
hands.  Performed  late,  after  many  examinations  have 
been  made  by  questionable  fingers  or  after  operations 
have  even  been  attempted,  cesarean  section  has  a very 
high  mortality,  and  the  children  also  often  die,  so  that 
even  if  the  mother  lives  the  object  for  which  she  has 
been  hazarded  is  lost  in  the  end. 

Preparation  for  Cesarean  Section. — The  preparations 
for  this  operation  are  mainly  those  for  laparotomy  in 
general.  In  addition,  provision  is  made  for  the  child. 

A preparatory  course  of  treatment  extending  over 
several  days  is  desirable,  but  not  absolutely  necessary. 
Daily  warm  baths  with  brisk  scrubbing  of  the  trunk  from 
the  ensiform  to  the  knees,  a light  laxative  with  enemata, 
plain  nourishing  food,  plenty  of  rest  in  bed,  and  walks  in 
the  sunshine  are  all  valuable  in  rendering  the  patient 
more  resistant  to  the  dangers  besetting  the  operation. 
The  urine  is  examined  for  evidences  of  nephritis,  and  the 
vaginal  discharge,  for  gonorrheal  infection. 

The  method  of  disinfection  of  the  skin  varies  with  dif- 
ferent practitioners.  One  commonly  used  is  as  follows: 
(1)  Shaving,  from  ribs  to  half-way  to  knees,  and  well 
down  the  flanks;  (2)  scrubbing  with  soft  brush  and 


204 


OBSTETRIC  OPERATIONS 


tincture  of  green  soap  for  five  minutes;  (3)  rinsing  with 
plain  water;  (4)  scrubbing  with  soft  brush  or  coarse 
cloth  and  alcohol,  95  per  cent.,  three  minutes;  (5)  scrub- 
bing with  1 : 1500  bichlorid  for  three  minutes;  or  (6) 
scrubbing  with  lysol,  1 per  cent.,  three  minutes;  (7) 


BASIN  ■ STAND 


□ □ □ 

TABLE.  WITH 

CIO 


TABLE.  WITH  INSTRUMENTS. 

SUTURE  MATERIAL, ETC. 


^IRS^ASSISTANT 


CLEAN\  NURSE 


^BATH  TUB  ^ 


O' 


(HOT9  (COLD) 
WATER 


TABLE  WITH 
TRACHEAL  CATHETER, 
TOWELS,  ETC. 


o 

.0 

r* 

b 

o 


Fig.  103. — Diagram  of  a room  arranged  for  cesarean  section. 


gauze  saturated  with  1 per  cent,  lysol  is  allowed  to  cover 
the  abdomen  until  the  operator  is  ready;  then  (8)  the  ab- 
domen is  washed  with  sterile  water.  The  sterile  laparot- 
omy sheet  is  now  adjusted.  Some  operators  use  alcohol 
entirely  as  a disinfectant,  others  rely  on  tincture  of  green 
soap.  Before  going  on  the  table  the  patient  is  catheter- 


SUPPLIES  NEEDED  FOR  CESAREAN  SECTION  2C>5 


ized.  Tincture  of  iodin  is  not  recommended.  The  vulva 
is  also  prepared,  but  no  vaginal  manipulations  are  made 
unless  ordered. 

For  the  operation  five  assistants  are  necessary:  An 
anesthetizer,  a first  assistant,  an  assistant  to  hand  instru- 
ments and  sponges,  one  to  receive  and  revive  the  child, 
and  a nurse,  not  aseptic,  to  handle  supplies  and  render 
general  services  about  the  patient.  The  less  the  num- 
ber of  hands  in  the  case,  the  better.  All  assistants 
should  wear  sterile  rubber  gloves,  and  extra  care  is 
to  be  taken  that  there  are  no  perforations  in  them. 
The  arrangement  of  tables  and  assistants  is  shown 
in  Fig.  103. 

List  of  Supplies  Needed  for  Cesarean  Section 

Twelve  small  laparotomy  sponges.  These  are  of  four 
thicknesses  of  gauze,  6 inches  square,  sewed  around  the 
edges  and  carrying  a piece  of  tape  10  inches  long  firmly 
fastened  to  one  corner,  with  a ring  or  hard  object  at- 
tached to  the  end. 

Six  large  laparotomy  pads.  These  are  of  six  thick- 
nesses of  gauze,  12  inches  square,  sewed  and  tacked, 
but  without  tapes. 

One  jar  of  small  surgical  gauze  sponges  or  pledgets. 

One  sterile  receiver  for  the  baby. 

One  laparotomy  sheet. 

Two  plain  sterile  sheets. 

One  dozen  towels. 

One  pair  leggings. 

Six  gowns  and  head-pieces  (Fig.  104). 

Four  pairs  rubber  gloves. 

Five  basins. 

One  pitcher,  besides  hot-  and  cold-water  supply 
pitchers. 


206 


OBS  TE  TRIC  OPERA  TIONS 


These  articles  are  sterilized  according  to  the  usual 
methods.  The  antiseptic  solutions  are  prepared  accord- 
ing to  the  physician’s  usual  practice. 


Fig.  104. — Head-  and  mouth-guard.  Pattern  of  Mercy  Hospital,  Chicgao. 


The  Instruments  for  Cesarean  Section 
Two  scalpels. 

Three  scissors,  one  angular. 

Three  tenaculum  forceps. 


CESAREAN  SECTION 


207 


Three  sponge-carriers. 

Twelve  artery  clamps. 

Eight  long  pedicle  clamps. 

Two  needle-holders. 

Two  broad  retractors. 

Two  rat- toothed  tissue  forceps. 

One  long  uterine  packing  forceps. 

Eight  full  curved  round  needles,  ij  inches,  for 
uterus. 

Six  shorter,  half-curved  spear-pointed  needles  for 
fascia. 

Two  long  straight  needles  for  skin. 

One  glass  hypodermic  syringe. 

One  dozen  large  safety-pins. 

Adrenalin,  1 : 10,000,  and  pituitrin  in  glass  ampoules. 

Suture  material.  The  physician  will  order  this.  No. 
6 silk  for  the  uterus;  No.  1 catgut  for  the  peritoneum; 
No.  2 catgut  for  fascia;  and  medium  silkworm-gut  for 
the  skin,  are  usually  used.  Some  operators  use  catgut 
throughout. 

Light,  Heat,  and  Anesthetic. — Special  arrangement 
must  be  made  for  light  if  the  section  is  to  be  performed 
in  a private  home.  The  room  must  be  quite  warm — at 
least  8o°  F. — as  the  peritoneum  is  much  exposed,  and  it 
is  well  that  the  air  be  damp,  so  that  there  is  no  dust. 
The  operating  table  should  be  covered  with  an  electric 
heating  pad,  or  a few  hot-water  bottles  laid  alongside 
the  patient.  She  must  be  guarded  from  chilling.  The 
anesthetic  usually  given  is  ether.  Just  before  the  anes- 
thetic is  started  a hypodermic  of  aseptic  ergot  or  of  pitui- 
trin is  administered.  The  nurse  should  provide  a little 
tray  with  the  anesthetic,  a working  and  tested  hypoder- 
mic syringe,  strychnin  tablets,  camphorated  oil,  aromatic 
spirits  of  ammonia,  and  ether,  ready  for  the  anesthetist. 
Tongue  forceps  are  not  necessary;  a skilful  anesthetist 


208 


OBSTETRIC  OPERATIONS 


will  hardly  ever  use  them.  Oxygen  should  be  at 
hand. 

The  Operation.  —The  field  having  been  prepared,  the 
sterile  sheet  and  towels  being  arranged  and  pinned,  and 
the  patient  sound  asleep,  a long  incision  is  made  in  the 
middle  line,  through  which  the  uterus  is  delivered.  It  is 
at  once  covered  with  sterile  towels  wrung  out  of  hot 
water.  The  operator  rapidly  cuts  into  the  uterus,  de- 
livers the  child  by  the  feet,  clamps  the  cord  in  two  places, 
cuts  between,  and  hands  the  infant  at  once  to  an  assist- 
ant or  a nurse  who  stands  beside  him  holding  a warm 
blanket  for  it.  The  operator  pays  no  attention  to  the 
child,  as  he  has  to  continue  the  operation,  but  the  assist- 
ant’s duty  is  to  revive  the  infant.  The  child  usually  is 
slow  in  beginning  to  breathe,  because  the  change  from 
intra-  to  extra-uterine  conditions  came  so  quickly. 
Patience  and  the  usual  methods  of  resuscitation  almost 
always  succeed.  (See  page  360.) 

The  operator  removes  the  placenta  and  membranes, 
and  then  covers  the  uterus  with  the  large  laparotomy 
pads  or  hot  towels.  The  temperature  of  the  water  from 
which  these  towels  are  wrung  should  be  120°  F.  The 
uterus,  if  it  is  not  removed  by  the  Porro  operation,  is 
now  carefully  sewed  up  again,  then  the  peritoneal  toilet 
is  performed,  and  the  abdomen  is  closed.  The  nurse 
has  carefully  counted  the  laparotomy  pads  and  sponges 
and  notified  the  operator  at  once  if  any  are  missing.  The 
dressing  of  the  wound  is  made  by  laying  a strip  of  gauze 
over  it  and  covering  both  with  collodion.  An  antiseptic 
powder  may  be  used  instead,  and  over  this  a large  oc- 
clusive dressing. 

Adhesive  straps  are  now  placed  to  support  the  abdom- 
inal wall,  but  care  is  to  be  taken  not  to  make  them  too 
tight. 


CESAREAN  SECTION 


209 


STEPS  OF  OPERATION 


Operator. 

1.  Puts  on  gloves.  1. 

2.  Incision  in  skin.  2. 

3.  Incision  of  fascia.  3. 

4.  Incision  of  peritoneum.  4. 

5.  Incision  of  uterus,  and  5. 

delivery  of  child. 

6.  Hemorrhage.  6. 

7.  Suture  of  uterus.  7. 

8.  Peritoneal  toilet.  8. 

9.  Sewing  peritoneum.  9. 

10.  Sewing  fascia.  10. 

1 1 . Sewing  skin.  1 1 . 


Nurse. 

Adjusts  sheets. 

Hands  knife  to  operator,  artery 
clamps  to  assistant. 

Second  knife  to  operator. 

Scissors  to  operator,  tissue  for- 
ceps to  assistant. 

Two  artery  clamps  for  cord. 
Sterile  receiver  for  infant. 

Wet  hot  large  pads,  injection 
of  1:10,000  adrenalin  into 
uterus,  suture  material. 

No.  2 catgut  or  No.  6 silk  on 
round  pointed  needles. 

Small  pads  wet  with  sterile 
water,  or  stick  sponge  in 
secure  holder. 

No.  1 catgut  on  same  needles. 
Count  pads. 

No.  2 catgut  on  sharp-pointed 
short  needles. 

Silk-gut  or  linen  on  long 
straight  needle. 


There  are  several  varieties  of  cesarean  section — the 
extraperitoneal,  the  transperitoneal,  the  flank  operation 
— but  the  classic  operation  is  the  one  here  described. 

The  After=care.  -This  is  identical  with  that  of  all 
laparotomies.  The  nurse  watches  for  signs  of  internal 
hemorrhage,  increasing  pulse-rate,  decreasing  fulness  of 
pulse,  pallor,  rapid  respiration,  yawning,  sighing,  etc. 
The  reaction  from  shock  should  be  noted,  likewise  its 
absence.  Persistent  vomiting  is  always  suspicious.  In 
addition  to  these  the  nurse  must  look  for  external 
bleeding  from  the  genitals,  as  patients  may  have  post- 
partum hemorrhage  after  cesarean  section.  The  abdomi- 
nal dressing  occasionally  requires  some  adjustment  that 
it  does  not  slip  and  expose  the  wound. 

Should  the  patient  vomit  persistently;  should  hemor- 
rhage appear  externally;  should  the  patient  not  rally 
quickly  from  the  shock  of  the  operation  or  should  this 

14 


210 


OBSTETRIC  OPERATIONS 


even  deepen;  or  should  internal  hemorrhage  be  suspected, 
the  physician  must  be  notified  without  delay. 

Hot  water,  i ounce  at  a time  and  freely,  will  assuage 
the  extreme  thirst,  and  salt  solution  per  rectum,  i pint 
every  six  hours,  will  help  to  do  the  same.  Milk  and 
lime-water  are  given  for  the  first  twelve  hours,  after 
which  liquid  diet  is  ordered. 

The  nurse  must  obtain  written  orders  from  the  phys- 
ician regarding  all  these  details  if  she  is  not  familiar  with 
his  practice.  The  instructions  here  given  are  to  indicate 
the  general  course  of  treatment  and  for  the  general  in- 
formation of  the  nurse. 

The  bowels  should  move  on  the  second  or  third  day, 
but  if  the  patient  passes  flatus  no  trouble  need  be 
anticipated  in  this  direction.  The  physician  usually 
orders  a cathartic,  to  be  followed  by  a colonic  flushing, 
the  composition  of  which  the  nurse  should  ascertain  from 
him.  Some  physicians  avoid  cathartics. 

Extreme  tympany,  persistent  nausea  and  vomiting, 
obstinate  constipation,  severe  pain,  hiccup,  fever  occur- 
ring at  any  time  after  the  operation,  are  to  be  noted  on 
the  history-sheet,  and  the  doctor’s  attention  drawn  to 
them.  Sometimes  they  indicate  a beginning  peritonitis. 

The  child  does  not  require  any  other  care  than  that 
given  after  normal  labor.  It  is  put  to  the  breast  twelve 
hours  after  the  operation  if  everything  goes  well,  and 
regularly,  as  per  schedule  given  on  page  160. 

Convalescence. — The  sutures  are  usually  removed  on 
the  eleventh  day.  The  physician  may  apply  adhesive 
strips  or  a firm  binder  to  support  the  wound.  The 
patient  sits  up  at  the  end  of  one  or  three  weeks,  depend- 
ing on  the  practice  of  the  operator. 

Vaginal  Cesarean  Section.  -When  rapid  delivery 
is  indicated  and  the  cervix  uteri  is  tightly  closed  the 
quickest  way  to  empty  the  uterus  is  by  an  operation 


PUBIOTOMY  OR  HEB OSTEOTOMY 


211 


called  vaginal  cesarean  section.  The  anterior  wall  of 
the  vagina  is  incised  and  the  bladder  pushed  forward, 
away  from  the  uterus,  and  then  the  anterior  wall  of  the 
uterus  is  divided  with  scissors,  making  an  opening  large 
enough  for  the  extraction  of  the  child.  The  perineum  is 
also  incised  if  necessary.  After  delivery  is  completed 
all  the  structures  are  reunited  by  suture. 

The  preparations  by  the  nurse  are  the  same  as  for 
forceps  operation  plus  those  for  vaginal  extirpation  of 
the  uterus  (hysterectomy). 

Symphysiotomy.  This  is  the  section  of  the  pubic 
joint  which  allows  the  innominate  bones  to  separate, 
and  thus  the  cavity  of  the  pelvis  is  enlarged.  The 
operation  was  invented  by  Sigault,  a medical  student,  in 
1773,  but  was  discarded  because  of  its  dreadful  mortality. 
Sigault’s  case,  the  wife  of  a gendarme,  dragged  out  a miser- 
able existence  after  its  performance  on  her,  but  Sigault 
was  given  a medal  for  devising  it.  About  1892  there 
was  a revival  of  the  operation,  because  the  blessings  of 
asepsis  rendered  it  quite  safe.  But  now  it  is  falling 
off  in  favor,  pubiotomy  and  cesarean  section  taking  its 
place. 

Pubiotomy  or  hebosteotomy  is  a new  operation, 
and  at  the  present  writing  the  enthusiasm  with  which 
it  was  received,  like  many  innovations  in  medicine,  has 
already  become  moderated  by  adverse  experience.  The 
operation  resembles  symphysiotomy  with  the  exception 
that  not  the  joint,  but  the  bone  near  the  joint  is  opened. 
A wire  saw  invented  by  Gigli  is  used,  and  the  section 
is  often  done  subcutaneously. 

Symphysiotomy  being  almost  completely  displaced  by 
pubiotomy,  the  latter  operation  will  be  described. 

There  are  three  stages  in  the  procedure : (1)  The  saw- 
ing open  of  the  pelvis;  (2)  the  delivery  of  the  child;  (3) 
the  repair  of  lacerations. 


212 


OBSTE  TR IC  OPERA  T/ONS 


The  Operation.  -The  patient  is  prepared  as  for  any 
major  obstetric  operation,  and  lies  on  the  table  with  the 
limbs  partly  extended.  The  Gigli  or  wire  saw  is  carried 


a 

Fig.  105. — Pubiotomy  needles:  a,  Bumm’s;  b,  Doderlein’s. 


around  the  back  of  the  pubic  bone  through  either  a 
small  incision  or  a puncture.  The  introduction  is 
effected  by  means  of  a large  needle  or  a special  carrier 
(Fig.  105).  After  the  bone  is  severed  the  child  is  de- 


PUBIOTOMY  OR  HE  BOS  TE  O TO  M\ 


213 


livered  by  forceps  or  version,  or  the  case  left  to  nature. 
The  ends  of  the  bone  separate  1 or  2 inches  during  the 
delivery  and  the  sides  of  the  pelvis  are  supported  by  the 
assistants. 

The  hemorrhage  and  lacerations,  if  present,  are  at- 
tended to,  the  bladder  catheterized  to  see  if  it  is  injured, 
and  the  patient  carefully  carried  to  bed.  Four  assistants 
are  needed  besides  the  nurse. 

List  of  Instruments 

Two  trays,  to  be  kept  separate. 

First  Tray: 

One  scalpel. 

Two  Gigli  wire  saws  (Fig.  106). 

One  special  carrier  or  large  needle  (Fig.  105). 

Scissors. 

One  broad  grooved  director. 

Four  artery  clamps. 

Four  8-inch  pedicle  clamps. 

Needle-holder. 

Four  full-curved,  spear-pointed  needles,  if  inches. 

Two  retractors. 

Uterine  sound  or  metal  catheter. 

Second  Tray: 

Forceps,  axis-traction  forceps,  and  all  instruments 
given  under  Forceps  Operation.  (See  p.  194.) 

The  operator  is  careful  not  to  mix  the  instruments  of 
the  two  trays.  The  first  tray  is  used  for  the  opening  of 
the  pelvis  and  closing  the  wounds  afterward.  The 
second  tray  is  used  for  the  second  stage  of  the  operation 
— the  delivery  part.  The  vagina  is  considered  septic, 
and  this  is  the  reason  for  the  two  separate  trays  of 
instruments. 

After  delivering  the  child  the  operator  resterilizes  his 
hands,  or  draws  on  new  sterile  gloves  before  going  again 


214 


OB  S'  7 E ERIC  OPERA  TIONS 


to  the  pubic  wound.  This  is  one  of  the  main  dangers  of 
the  operation,  that  the  pubic  wound  will  become  infected 
from  the  vagina,  and  the  nurse  has  to  do  her  share  to 
prevent  it  in  the  puerperium. 


After=care  of  Symphysiotomy  and  Pubiotomy.—  It  is 

highly  important  that  the  patient  be  given  intelligent 
nursing,  as  she  is  practically  paraplegic  after  such  opera- 
tions. For  the  first  few  days  she  does  not  have  the  use 
of  her  limbs — she  cannot  raise  the  hips  and  should  not 


PUB10T0MY  OR  HEBOSTEOTOMY 


215 


try  to  do  so.  The  integrity  of  the  pelvic  girdle  is  tem- 
porarily destroyed. 

The  patient,  after  the  operation,  is  dressed  with  ad- 
hesive strips  about  the  pelvis  to  support  the  bones  in 
apposition,  or  this  is  done  by  a tight  binder  strapped  on. 
She  is  placed  on  a special  symphysiotomy  bed,  if  one  is 
obtainable,  though  this  is  not  absolutely  necessary;  any 
nurse  can  improvise  such  an  apparatus,  the  idea  being 
to  have  the  bed  arranged  so  that  the  patient  may  be 
raised  up  for  the  use  of  the  bed-pan  and  for  dressings. 
The  plumber  may  make  a frame  of  J-inch  iron  gas-pipe, 


32  by  66  inches,  or  long  enough  to  fit  inside  the  bed. 
The  nurse  then  covers  this  frame  with  strong  muslin,  as 
shown  in  Fig.  107.  At  the  middle,  where  the  buttocks 
will  lie,  the  strips  of  muslin  are  to  be  pinned  at  the  side 
with  strong  safety-pins.  When  the  patient  is  raised  off 
the  bed  these  strips  are  unpinned  and  access  to  the  gen- 
itals is  thus  obtained. 

This  frame  may  be  raised  by  means  of  four  ropes 
attached  to  the  corners  and  running  through  pulleys  in 
the  ceiling,  or  it  may  be  lifted  onto  four  hooks  hanging 
on  the  head  and  foot  of  the  bed,  as  shown  in  Fig.  108. 


2l6 


OBSTETRIC  ORERATIONS 


The  bed  is  dressed  as  usual,  the  frame  is  laid  on  it, 
and  the  patient  lies  on  the  muslin  strips.  When  neces- 
sary to  make  a dressing  or  give  the  patient  the  usual 
attentions,  the  frame  is  raised  about  12  inches.  The 


strips  beneath  the  vulva  are  loosened  and  drawn  aside. 
This  arrangement  simplifies  extraordinarily  the  after- 
care of  these  cases,  which  at  best  is  trying  and  tedious. 
The  nurse  should  watch  for  a hematoma,  a blood-clot 


MINOR  OPERATIONS 


21 7 

around  the  pubic  joint,  which  is  not  infrequent  after 
hebosteotomy,  and  for  signs  of  injury  to  the  bladder. 
If  a retention  catheter  has  been  inserted  the  nurse  must 
be  sure  that  it  is  draining  without  interruption.  (See 
F'g-  iSS-) 

Particular  care  is  necessary  to  prevent  the  lochia  from 
gaining  access  to  the  wound  in  the  mons  pubis.  To 
avoid  this  the  nurse  adjusts  the  vulvar  pad  firmly  above, 
loosely  below,  so  that  the  lochia  will  have  free  flow 
downward,  and  arranges  the  wound  dressing  so  as  to 
keep  the  wound  covered. 

Catheterization  is  particularly  difficult  because  the 
patient  is  not  allowed  to  separate  the  limbs  more  than  a 
few  inches.  By  turning  the  toes  inward  the  nurse  may 
part  the  knees  without  causing  much  pain. 

After  two  weeks  the  frame  may  usually  be  dispensed 
with.  Several  weeks  may  pass  before  the  patient  is 
able  to  resume  her  household  duties. 

MINOR  OPERATIONS 

Minor  operations  are  as  important  as  any,  and  should 
be  prepared  for  with  the  usual  aseptic  care. 

Preparation  for  Obstetric  Examination.  The 
nurse  is  expected  to  arrange  a patient  for  the  digital 
obstetric  or  gynecologic  examination  quickly  and  neatly. 
A basin  of  i per  cent,  lysol  solution,  a supply  of  pledgets, 
and  a sheet  are  necessary.  If  the  physician  desires  the 
patient  across  the  bed  she  is  placed  as  in  Fig.  51.  The 
sheet  is  laid  on  the  bias  over  the  trunk,  the  opposite 
corners  are  wrapped  around  the  legs,  while  the  two  re- 
maining corners  are  draped  one  over  the  body,  and  the 
other  to  form  a flap  which  hangs  between  the  thighs  till 
the  examination  is  about  to  be  made.  The  nurse  will 
sponge  the  parts  carefully  herself  before  the  physician 
inspects  them,  and  will  report  to  him  the  presence  of 


2 1 8 


OBSTETRIC  ORE  RATIONS 


bloody,  purulent,  or  odorous  discharge.  The  patient’s 
limbs,  as  shown  in  Fig.  51,  are  supported  by  the  nurse. 
They  may  be  allowed  to  rest  on  two  chairs  or  on  the 
knees  of  the  physician. 

Occasionally  the  nurse  is  requested  to  arrange  the 
patient  obliquely  on  the  bed  with  one  foot  resting  on  a 
chair  (Fig.  109). 


Fig.  109. — Patient  obliquely  in  bed,  draped  with  a sheet,  prepared  for  internal 
examination.  One  limb  rests  on  a chair,  the  other  on  the  edge  of  the  bed.  The 
buttocks  are  near  the  edge  of  the  bed,  which  is  protected  by  a newspaper  covered 
with  a towel. 


Perineorrhaphy.  -The  most  common  of  minor  oper- 
ations is  perineorrhaphy,  or  the  repair  of  lacerations  of 
the  pelvic  floor.  Most  physicians  repair  these  tears 
immediately  after  labor.  Others  leave  them  for  two 
weeks,  and  a very  few  defer  operation  to  a period  of 
several  months  afterward. 


MINOR  OPERATIONS 


219 


For  a perineorrhaphy  after  labor  the  patient  is  usually 
put  across  the  bed  in  the  lithotomy  position  (Fig.  90). 
If  the  laceration  is  more  than  small,  it  is  wiser  to  use  the 
table,  as  much  better  work  can  be  done.  The  operation 
has  already  been  described  on  p.  129. 

The  after-treatment  of  stitches  does  not  differ  much 
from  the  usual.  Extra  care  must  be  taken  not  to. pull 


Fig.  1x0. — Patient  across  the  bed,  draped  with  a sheet,  for  removal  of  sutures. 
The  instruments  lie  in  the  basin  in  which  they  were  boiled  or  upon  a sterile 
towel:  Speculum,  2 artery  forceps,  x tissue  forceps,  2 scissors. 


on  the  knots  when  a dressing  is  made  or  a bed-pan  is 
used;  also  that  the  suture  ends  do  not  catch  in  the 
dressing  and  drag  on  the  wound  Should  the  patient 
complain  of  the  ends  of  the  sutures  pricking  her,  the 
nurse  may  wrap  them  in  sterile  gauze  or  let  them  lie 
between  two  layers  of  gauze.  At  each  dressing  notice  is 
taken  of  any  signs  of  irritation,  swelling,  special  tender- 


220 


OBSTETRIC  OPERATIONS 


ness,  or  pus-formation,  or  of  cutting  around  the  stitches 
or  line  of  union,  and  a note  is  made  of  same  on  the  record- 
sheet. 

The  parts  around  the  wound  should  occasionally  be 
washed  with  soap  and  water  to  remove  dried  secretions 
and  macerated  epithelium. 

Removal  of  Sutures. — Catgut  does  not  need  to  be 
removed;  silk  and  silkworm-gut  do.  This  is  done  on 
about  the  tenth  day. 

The  nurse  sterilizes  two  sharp-pointed  scissors,  one 
long,  one  short,  artery  forceps,  one  tissue  forceps,  and  a 
short,  narrow,  highly  polished  speculum  (Fig.  no). 
The  physician  requires  excellent  light.  The  provisions 


for  asepsis  are  as  usual  (sterile  gloves,  etc.),  and  the 
arrangement  of  the  patient,  tables,  and  basins  is  similar 
to  that  used  when  the  perineorrhaphy  was  done.  As 
there  is  often  a shortage  of  assistants,  the  nurse  should 
arrange  everything  in  readiness  for  the  physician  to 
wait  on  himself.  Then  she  holds  the  legs  as  in  Fig.  iio. 

The  sheet-sling  may  be  used  or  each  foot  placed  on 
a chair.  The  patient  should  rest  quietly  for  several 
hours  after  the  sutures  are  removed. 

Uterine  Tamponade.  -The  tamponade  or  packing 
of  the  uterus  with  gauze  is  done  to  control  postpartum 
hemorrhage,  and  also  by  some  accoucheurs  in  the  treat- 
ment of  puerperal  sepsis.  The  physician  needs  specula, 
vulsellum  forceps,  long  uterine  packing  forceps  (Fig.  in), 


MINOR  OPERATIONS 


221 


and  a jar  of  sterilized  or  antiseptic  gauze.  This  gauze 
should  be  J yard  wide  and  12  yards  long,  and  packed 


in  jars  from  below  upward,  so  that  when  needed  it  may 
be  served  right  out  of  the  jar  (Fig.  112).  If  the  avail- 


Fig.  1x2. — The  operation  of  packing  the  uterus,  showing  how  the  nurse  holds  the  gauze  near  the  vulva. 


222 


OBSTETRIC  ORE  RATIONS 


able  gauze  is  rolled,  the  roll  may  be  served  out  of  a 
sterile  basin,  or  from  two  forceps  attached  to  the  center, 
as  in  Fig.  113. 

The  patient  is  arranged  across  the  bed  or  on  a table 
in  the  lithotomy  position.  For  this  operation  the  limbs 
may  be  supported  on  chairs.  The  nurse  wraps  the  jar 
in  a sterile  towel  and  holds  it  against  the  buttock,  about 
2 inches  below  and  to  the  side  of  the  vulva.  The 
physician  picks  up  the  end  of  the  gauze  with  long 
forceps  and  carries  it  into  the  uterus,  which  he  has 


Fig.  X13. — Showing  how  nurse  unrolls  gauze  by  means  of  two  forceps  as  the 
doctor  packs  it  into  the  uterus.  Rubber  gloves,  etc.,  are,  of  course,  used  in 
actual  practice. 


drawn  down  with  vulsella,  or  steadies  with  two  fingers 
of  the  other  hand  (Fig.  112). 

After  the  uterus  is  packed  a pad  is  applied,  and  then 
the  binder.  Special  care  must  be  taken  in  moving  pa- 
tients that  are  tamponed,  as  the  uterus  may  stretch  dan- 
gerously tight  over  the  packing  or  even  rupture  if  the 
patient  is  tossed  about. 

The  Douche. — The  practice  of  vaginal  and  uterine 
douching  after  labor  has  undergone  nearly  a complete 
reversal  in  the  last  fifteen  years.  Whereas  formerly  it 


THE  DOUCHE 


223 


was  thought  that  douching  aided  recovery  and  prevented 
puerperal  infection,  accumulated  experience  has  proved 
that  the  irrigations  in  normal  cases  are  at  least  super- 
fluous, and  indicated  only  in  pathologic  cases.  Even 
here  medical  opinions  differ  as  to  their  value. 

The  vaginal  douche  is  a much  simpler  procedure  than 
the  uterine  douche,  and  the  latter  the  nurse  ought  not  be 
called  upon  to  give,  although  with  a little  special  instruc- 
tion she  can  learn  to  practice  it.  The  dignity  nowadays 
accorded  the  uterine  douche  places  the  responsibility  on 
the  physician. 

The  Vaginal  Douche. —The  arrangement  for  giving  the 
douche  is  pictured  in  Fig.  151.  The  aseptic  prepara- 
tions are  as  usual.  For  vaginal  douching  the  patient 
lies  on  her  back  in  bed  on  a douche-pan,  which  should 
be  sterile.  The  douche-bag  and  nozzle  should  be 
freshly  sterilized,  and  sterilized  water,  saline  solution, 
lysol  used,  according  to  special  order.  For  the  vaginal 
douche  the  point  is  inserted  2\  inches  downward  and 
backward,  avoiding  the  perineum.  The  bag  should  be 
no  more  than  2 feet  above  the  patient,  and  the  return 
flow  from  the  vagina  must  be  free,  which  is  accomplished 
by  pressing  the  tube  slightly  against  the  side  of  the 
vulva.  The  nurse  must  have  sterile  hands  or  wear  rub- 
ber gloves.  One  quart  is  usually  sufficient.  The  patient 
is  asked  to  bear  down  a little  to  express  any  liquid  re- 
maining in  the  vagina,  the  parts  are  gently  dried,  and 
the  douche  pan  is  removed.  The  nurse  observes  and 
notes  any  clots  or  shreds  that  have  come  away,  and  also 
the  odor  of  the  discharge.  If  bichlorid  or  carbolic  acid 
is  ordered  as  a douche,  it  should  be  followed  by  sterile 
water,  and  care  taken  that  the  proportion  is  right  and 
the  mixture  perfect.  Cases  of  fatal  poisoning  are 
recorded  due  to  neglect  of  these  precautions,  which  are 
as  necessary  in  private  homes  as  in  hospitals. 


224 


OBSTETRIC  OPERATIONS 


The  Uterine  Douche.  -For  this  the  patient  is  usually 
placed  across  the  bed  or  on  a table,  as  often  it  is  com- 
bined with  a digital  palpation  of  the  interior  of  the 
womb.  A broad  speculum,  two  vulsellum  forceps,  a 
long  uterine  applicator,  and  a uterine  douche  point 
should  be  boiled.  Sterile  tubes  for  cultures  should  be 
provided. 

Plenty  of  sterile  water  is  needed,  as  these  douches  are 
often  copious.  The  patient  is  placed  on  a Kelly  pad  or 
on  a rubber  sheet  draped  over  a roll  of  newspapers. 
The  floor  is  properly  protected  and  a drainage  pail  pro- 
vided. 

The  patient  must  be  kept  quiet  after  this  operation. 
Not  seldom  it  is  followed  by  a chill  and  rise  of  tem- 
perature. 

Uterine  Curettage.  -This  operation  is  done  in  the 
treatment  of  puerperal  infection,  and  its  object  is  to 
remove  pieces  of  decidua  or  placenta  that  are  retained 
and  decomposing  in  the  uterus.  Physicians  differ  as  to 
the  advisability  of  the  practice.  It  is  also  performed  in 
cases  of  abortion. 

The  preparations  are  the  same  as  for  a major  opera- 
tion— table,  anesthetic,  hot  and  cold  sterile  water,  sterile 
gloves,  etc.  The  instruments  required  are  specula, 
curets,  as  the  physician  selects,  uterine  packing  forceps, 
cervix  forceps,  vulsella,  uterine  douche  tube,  scissors, 
sterile  glass  for  specimen,  test-tubes  for  cultures.  A 
basin  of  sterile  water  in  which  the  operator  may  rinse  the 
curet  of  adherent  particles  of  tissue  should  be  placed  at 
his  side.  Gauze — -iodoform,  lysol,  or  plain  sterilized — 
for  packing  the  uterus  may  be  needed. 

Since  these  operations  are  done  for  septic  cases  the 
nurse  should  be  careful  of  her  hands,  not  to  prick  her 
fingers  on  the  instruments,  and  not  to  carry  infection  to 
the  mother’s  breasts  or  the  child’s  eyes  or  navel. 


LIST  OF  INSTRUMENTS  FOR  HYPODERMOCLYSIS  225 


The  Administration  of  Saline  Solution.  One 

of  the  most  precious  additions  to  our  means  for  saving 
life  is  the  use  of  saline  solution  transfusion.  In  the  olden 
time  blood  from  another  person  was  transfused  in  cases 
of  severe  hemorrhage,  and  many  cases  are  on  record  of 
such  heroic  sacrifice,  but  only  recently  has  the  direct 
transfusion  of  human  blood  been  practicable  and  safe. 
In  1881  Schwartz  showed  that  salt  solution  could  be 
used  for  supplying  loss  of  blood  in  animals,  and  von  Ott 
and  Bischoff  were  the  first  to  employ  the  measure  in  the 
treatment  of  anemic  patients. 

There  is  but  little  doubt  in  the  minds  of  surgeons  and 
accoucheurs  that  the  use  of  salt  solution  for  their  various 
purposes  saves  lives. 

An  expensive  apparatus,  though  more  convenient,  is 
not  necessary  except  in  hospitals,  where  the  operation  is 
frequently  done. 

The  saline  solution  may  be  injected  under  the  skin 
(hypodermoclysis)  or  by  intravenous  administration. 

List  of  Instruments  for  Hypodermoclysis 

One  2 -quart  douche-bag  or  can  with  tube  6 feet  long. 

One  1 -quart  measure. 


Fig.  1 14. — Author’s  needle  used  for  hypodermoclysis,  with  stem  and  protecting 

cover. 

One  bath-thermometer,  registering  over  2120  F.  This 
is  removed  from  its  wooden  case. 

One  salt  solution  needle  (Fig.  114). 


15 


226 


OBSTETRIC  ORE  RATIONS 


For  intravenous  transfusion  add: 

One  small  sharp  scalpel. 

Two  small  curved  needles. 

One  sharp-pointed  scissors. 

Two  fine  rat- toothed  dissecting  forceps. 

Three  artery  forceps. 

One  fine-pointed  medicine-dropper  or  special  trans- 
fusion cannula  (Fig.  115). 

Several  strands  of  silk. 

One  tourniquet  for  the  arm.  Do  not  forget  to  remove 
it  before  the  fluid  is  injected. 

In  a private  house  the  nurse  will  proceed  as  follows: 
The  2-quart  douche-bag  or  can  and  tube,  the  1 -quart 
measure,  and  the  bath-thermometer  are  put  on  to  boil  in 
1 per  cent,  soda  solution.  The  rubber  goods  must  be 

c 

Fig.  1 1 5. — Glass  cannula  for  intravenous  transfusion. 

wrapped  in  several  layers  of  towel.  They  are  boiled 
vigorously,  tightly  covered  for  fifteen  minutes,  and  are 
rinsed,  inside  and  out,  with  hot  sterile  water.  The 
instruments  are  sterilized  separately  and  served  out  of 
the  pan  in  which  they  were  boiled. 

Salt  solution,  0.7  per  cent.,  is  that  most  generally 
employed,  though  sometimes  other  chemicals  are  added. 
It  is  made  by  dissolving  2 drams  of  common  table  salt 
in  1 quart  of  water.  In  practice  2 teaspoonfuls  to  1 
quart  will  give  accurate  enough  dosage.  Unless  the  salt 
has  been  previously  sterilized,  the  solution  when  made  up 
must  be  boiled  vigorously  for  fifteen  minutes,  in  a tightly 
covered  vessel. 

Distilled  water  should  not  be  used,  the  small  amount 
of  calcium  in  hydrant  water  being  needed  by  the 


SALT  SOLUTION 


227 


blood.  This  fact  is  supported  by  physiologic  ex- 
periment. 

After  boiling  the  required  time  the  solution  is  poured 
into  the  douche-bag,  the  mouth  of  same  stoppered  with 
a large  pledget  of  sterile  cotton,  and  the  side  of  the  bag 
held  under  the  cold-water  tap.  The  thermometer  is 


Fig.  1 1 6. — Cooling  the  prepared  saline  solution  under  the  cold-water  tap. 

inserted  alongside  the  cotton  (Fig.  1 16).  In  this  way  the 
solution  is  quickly  brought  to  the  right  temperature- 
no0  to  1200  F. — as  ordered.  By  the  time  the  fluid 
reaches  the  patient,  passage  through  the  long  tube  will 
have  cooled  it  off  several  degrees. 

The  skin  is  prepared  by  scrubbing  with  water  and  soap, 


228 


OBSTETRIC  OPERATIONS 


with  lysol  and  alcohol,  or  by  painting  heavily  with 
tincture  of  iodin. 

For  subcutaneous  transfusion  (Fig.  1 17)  the  area  under 
the  breasts  is  often  selected;  for  intravenous  (Fig.  118), 


Fig.  1 1 7. — The  subcutaneous  administration  of  saline  solution. 


the  large  vein  in  the  bend  of  the  elbow.  With  the  sub- 
cutaneous method  the  bag  is  raised  5 feet  above  the 
patient  to  obtain  sufficient  pressure;  for  the  intravenous 
method  a height  of  18  inches  gives  sufficient  force. 


Fig.  118. — The  intravenous  administration  of  saline  solution. 


SALT  SOLUTION 


229 


A shorter  tube  is  used.  The  puncture  under  the  breast 
may  be  sealed  with  collodion,  with  adhesive  plaster,  or 


closed  with  a Michel  clip.  In  the  absence  of  either,  the 
solution  may  be  prevented  from  escaping  from  the  needle 


230 


OBS TE  ERIC  OPERA  T10NS 


puncture  by  holding  a pledget  soaked  in  alcohol  over  it  for 
a few  minutes.  The  wound  in  the  bend  of  the  elbow  is 
dressed  aseptically  under  firm  compression. 

The  Induction  of  Premature  Tabor.  -This  opera- 
tion is  quite  often  done,  the  reasons  being:  contracted 
pelvis  in  the  mother  (a  small,  premature  child  may  pass) ; 
threatened  convulsions  (eclampsia) ; placenta  praevia,  and 
many  others. 

There  are  several  methods,  the  most  reliable  ones 
being  the  insertion  of  rubber  catheters  into  the  uterus 
(Krause) ; of  long  strips  of  gauze,  and  of  rubber  bags  filled 
with  water  after  being  laid  inside  the  cervix.  With 
extreme  asepsis  the  induction  of  labor  has,  of  itself,  no 
mortality,  and  the  women  do  not  sicken.  If  antiseptic 
precautions  are  neglected  the  operation  is  dangerous. 

Preparations  are  the  same  as  for  any  major  obstetric 
operation. 

Instruments  Needed 

For  the  rubber-bag  method,  a colpeurynter  or  Barnes’ 
bag  (Figs.  1 19,  120). 

A long  uterine  dressing  forceps. 

Two  specula. 

Two  vulsella. 

Scissors. 

Two  short  artery  forceps. 

One  bulb  or  piston  syringe,  in  working  order. 

One  strand  linen  bobbin,  20  inches  long. 

For  Krause’s  method,  add  two  soft-rubber  solid 
bougies  (size  16,  American). 

For  the  gauze  method,  add  a tubular  packer  (Fig. 
1 21)  and  a supply  of  sterile  gauze  to  fit  the  instrument. 

The  catheters  and  all  soft-rubber  goods  are  sterilized 
by  boiling  in  pure  water  for  thirty  minutes  in  a tightly 
closed  vessel.  They  must  be  wrapped  in  at  least  four 


THE  INDUCTION  OF  PREMATURE  LABOR  23  I 


Fig.  1 19. — Various  types  of  balloon  dilators:  a,  b,  Voorhees’;  c,  Carl  Braun’s 
colpeurynter;  d,  Barnes’;  e,  Hirst’s;  /,  Champetier  de  Ribes’;  g,  air  pessary; 
h,  Pomeroy’s;  i,  bougie. 


232 


OBSTETRIC  OPERATIONS 


layers  of  a thick  towel  to  insure  them  against  being 
burnt  by  lying  against  the  hot  metal.  Hard-rubber 


syringes  are  sterilized  by  formalin  or  prolonged  immer- 
sion in  i : 500  bichlorid. 


Fig.  120. — Filling  the  colpeurynter. 


THE  INDUCTION  OF  PREMATURE  LABOR  233 


A vaginal  douche  is  usually  given,  and  the  patient  is 
placed  across  the  bed  or  on  a table,  as  for  any  obstetric 
operation. 

The  object  of  the  operation  is  to  induce  labor-pains,  to 
inaugurate  labor,  after  which  the  case  is  left  to  nature  or 
treated  as  any  labor  coming  on  spontaneously  at  the 
same  period  of  pregnancy. 


Fig.  1 21. — Tubular  gauze  packer. 


The  bougies  lying  in  the  uterus  irritate  it  to  contrac- 
tion, as  does  also  the  rubber  bag.  The  latter,  in  addi- 
tion to  being  an  irritant,  mechanically  dilates  the  cervix. 
Pains  come  on  in  a few  minutes  or  hours,  or  perhaps  not 
for  days,  although  it  is  not  usual  for  the  doctor  to  leave 
the  instrument  in  the  uterus  for  this  length  of  time. 
The  procedure  is  sometimes  very  tedious.  If  the  labor 
is  induced  before  term,  the  nurse  should  have  the  in- 
cubator ready.  (See  pages  368-374.)  She  should  enter 
the  advent  of  the  labor-pains  on  the  history-sheet, 


234 


OBSTETRIC  OPERATIONS 


and  record  the  time  of  each  pain  until  they  are  well 
established. 

Therapeutic  Abortion. — This  term  is  used  to  dis- 
tinguish the  operation  of  ending  the  pregnancy  before  the 
child  is  viable  from  the  criminal  operations  performed  by 
midwives  and  professional  abortionists. 


Fig.  122. — The  instruments  for  the  treatment  of  abortion  and  the  operation 
of  curettage:  Lower  row:  uterine  douche  nozzle;  3 placenta  forceps;  uterine 
packing  forceps;  tubular  uterine  packer  with  pronged  plunger;  curets,  four 
sizes;  uterine  dilators,  two  sizes.  The  upper  row:  2 sounds;  1 artery  clamp; 
2 scissors;  2 retractors;  2 vulsellum  forceps.  Some  operators  prefer  Hegar’s 
graduated  bougie  dilators  (Fig.  123). 


Perhaps  the  saddest  commentary  on  our  “modern 
civilization,”  on  our  “higher  thought,”  on  our  “ethical 
movement,”  is  the  increase  of  the  practice  of  criminal 
abortion.  Nurses  are  not  long  in  training  before  they 
see  how  alarmingly  this  crime  has  spread,  and  they  see, 


THERAPEUTIC  ABORTION 


235 


too,  the  lives  lost  and  the  homes  wrecked  by  it.  A 
nurse  should  never  be  party  to  such  a procedure.  It  is 
murder  and  often  suicide,  and  by  gentle  counsel  she 
should  dissuade  the  woman  from  entertaining  the  thought 
of  its  commission. 


Fig.  123. — Three  sizes  of  Hegar’s  dilators.  There  are  twenty-four  sizes. 

Very  rarely  the  conscientious  physician  is  compelled 
to  sacrifice  a tender  life  in  the  mother’s  womb.  Such 
occasions  are:  Uncontrollable  vomiting,  Bright’s  disease, 
and  a few  others.  The  accoucheur  feels  here,  as  he  did 
while  doing  a craniotomy  on  the  living  child,  that  the 
best  interests  of  the  mother,  the  family,  and  the  com- 
munity are  served  by  this  sacrifice.  The  operation,  how- 


236 


OBSTETRIC  OPERATIONS 


ever,  awakens  feelings  of  greatest  delicacy;  it  involves 
heavy  and  painful  responsibilities,  and  no  physician  will 
perform  it  without  the  counsel  and  moral  support  of  at 
least  one  of  his  confreres. 

The  preparations  are  the  same  as  for  the  induction  of 
labor,  the  instruments  are  the  same,  with  the  addition  of 
uterine  dilators  and  curets  (Fig.  122). 

A basin  with  sterile  water  is  to  be  provided  in  which 
the  operator  may  float  particles  cureted  out  for  inspec- 
tion. The  parts  of  the  fetus  removed  piecemeal,  arms, 
legs,  etc.,  should  be  fitted  together  to  make  sure  that  the 
whole  body  has  been  extracted. 

The  after-care  is  identical  with  that  of  the  normal 
puerperium. 


PART  III 


THE  PATHOLOGY  OF  PREGNANCY,  LABOR, 
AND  THE  PUERPERIUM 


CHAPTER  I 

OBSTETRIC  COMPLICATIONS 

DISORDERS  OF  PREGNANCY 

Ordinarily  pregnancy  and  parturition  are  considered 
normal  processes,  but  they  are  attended  with  many  dis- 
comforts, so  that  the  patient  is  often  rendered  miserable, 
and  these  conditions  run  so  close  to  the  pathologic  that 
the  dividing  line  is  very  narrow.  Mauriceau,  a famous 
French  obstetrician,  said  pregnancy  is  a disease  of  nine 
months’  duration.  Some  women  feel  better  while  preg- 
nant than  at  any  other  time. 

Nausea  and  Vomiting.  -About  one-third  of  preg- 
nant women  have  this  symptom.  It  varies  much  in  dif- 
ferent women  and  in  succeeding  pregnancies.  If  the 
patient  retains  most  of  her  food,  if  the  general  health  is 
not  concerned,  the  physician  usually  is  not  alarmed,  but 
prescribes  only  mild  palliative  measures.  Such  are:  (i) 
Waking  the  patient  at  about  6 a.m.  and  giving  her  a cup 
of  coffee  with  a bit  of  toast,  the  patient  resting  an  hour 
or  two  afterward;  (2)  counterirritation  over  the  stomach; 
(3)  the  knee-chest  position  (see  Fig.  124);  (4)  mild  medi- 
cines, as  oxalate  of  cerium  and  bismuth;  (5)  laxatives. 

237 


238 


OBSTETRIC  COMPLICATIONS 


Hyperemesis  Gravidarum.  If  the  woman  vomits 
continually,  if  her  health  begins  to  suffer,  the  case  is 


serious  and  must  be  handled  firmly.  Symptoms  of  the 
ordinary  nausea  becoming  “uncontrollable”  or  “per- 


24. — The  knee-chest  position. 


HYPEREMESIS  GRAVIDARUM 


239 


nicious”  are:  Constancy  of  nausea  and  great  frequency 
of  vomiting;  exhaustion;  loss  of  weight  and  of  sleep; 
salivation;  hematemesis;  fever,  and  rapid  pulse.  The 
last  three  show  that  the  disease  is  far  advanced. 

The  nursing  of  a case  of  hyperemesis  gravidarum 
requires  the  highest  kind  of  nursing  skill  and  culinary 
ability. 

Besides  the  administration  of  the  prescribed  medicines 
the  nurse  may  have  to  assist  at  washing  out  of  the  stom- 
ach, the  application  of  electricity,  hypodermic  injection 
of  saline  solution,  gynecologic  treatment  of  the  patient, 
such  as  raising  the  uterus  with  tampons  or  the  colpeu- 
rynter,  even  the  operation  of  therapeutic  abortion.  The 
actual  nursing  and  feeding  contribute  immensely  to  the 
success  of  the  physician’s  remedies. 

The  pleasantest  and  airiest  room  in  the  house  should 
be  selected  for  the  patient.  It  should  be  darkened. 
She  should  be  left  alone  with  her  nurse,  all  friends  and 
nearly  all  relatives  being  excluded.  It  is  sometimes 
beneficial  to  exclude  every  one — the  husband  also — for  a 
week  or  more.  The  nurse  should  distract  the  patient’s 
mind  from  herself  and  from  the  idea  of  vomiting;  there- 
fore the  emesis  basin  should  be  hidden  until  actually 
required. 

A soap-and-water  bath  is  given  daily,  followed  by  a 
rub  with  eau  de  Cologne  or  Florida  water.  The  appe- 
tite is  tempted  with  light  foods  served  in  the  daintiest 
possible  manner,  using  the  whitest  linen  and  the  prettiest 
dishes.  Occasionally  a few  sips  of  champagne  may  settle 
the  stomach,  so  that  food  can  be  retained,  or  a hypoder- 
mic of  heroin  is  given  just  before  the  food  is  taken,  or 
bromide  given  per  rectum. 

At  the  beginning  the  following  may  be  the  dietary: 

Milk  and  lime-water  or  seltzer,  ice  cold. 

A strong  beef-broth  served  in  a cup,  with  salted  wafers. 


240 


OBSTETRIC  COMPLICATIONS 


Cold  custard. 

Rice  and  milk,  with  cinnamon. 

A sliver  of  white  meat  of  chicken,  with  buttered  toast. 
Strong  oyster  broth. 

Strained  oyster-stew. 

Toast  and  hot  milk,  with  sugar. 

Ice-cream  and  ices. 

Cream  soups,  with  wafers. 


Fig.  125. — The  “Ideal”  drinking  glass. 


The  food  should  be  given  while  the  patient  is  in  the 
horizontal  position,  and  she  should  lie  perfectly  quiet 
for  a few  minutes  afterward.  The  “Ideal”  drinking 
glass  (Fig.  125)  is  very  convenient  for  drinking  in  this 
position. 

Should  these  measures  fail,  liquid  diet  will  have  to  be 
ordered.  This  consists  of  milk,  milk  and  seltzer  or  lime- 
water,  peptonized  milk,  plenty  of  water,  beef,  mutton, 
and  chicken  broths,  albumin- water,  sugar-water,  barley- 


H YPEREMESIS  GRA  VIDA  R UM 


24I 


water,  and  beef-juice.1  Some  patients  do  better  on 
solid  food,  toast,  crackers,  and  meat,  the  liquids  being 
supplied  by  rectum. 

If  the  patient  vomits  in  spite  of  all  this,  the  physician 
will  usually  order  everything  by  mouth  stopped  and  rec- 
tal feeding  instituted. 

Physicians  seldom  allow  patients  to  continue  long  in 
this  condition,  as  a turn  for  the  worse  may  come  on  sud- 
denly, and  the  patient  be  lost  before  measures  for  saving 
her  can  be  instituted.  Occasionally,  even  when  condi- 
tions appear  quite  serious,  the  woman  suddenly  ceases 
to  vomit,  demands  food,  and  retains  it.  Sometimes  a 
psychic  shock,  or  mental  influence,  or  the  phenomenon 
of  “quickening”  must  be  accepted  as  the  cause,  and  not 
the  doctor’s  medicines. 

Should  a consultation  of  physicians  decide  to  terminate 
the  pregnancy  as  the  only  hope  of  saving  the  patient,  the 
nurse  will  set  about  preparing  as  for  a major  operation. 
(See  Therapeutic  Abortion,  pp.  234,  235.) 

Shock  is  marked  in  these  cases,  and  ample  provision 
ought  to  be  made  to  combat  it.  After  the  operation  the 
vomiting  nearly  always  ceases  or  becomes  less.  Was  the 
operation  performed  too  late,  acute  exhaustion  super- 
venes and  the  patient  sleeps  away.  Careful  nursing  after 
the  operation  is  needed,  and  all  the  intricate  arts  of  the 
cook  will  be  useful.  Nourishment  should  be  given  as 
previously  indicated.  If  the  rectum  tolerates  it,  rectal 
feeding  is  practised  in  addition,  and  inunctions  of  ben- 
zoinated  lard  are  made.  Some  of  the  lard  is  absorbed 
as  a food.  To  supply  liquids  to  the  body,  salt  solution 
may  be  given  by  the  drop  method  per  rectum  or  by  hy- 
podermoclysis,  and  everything  done  to  bring  the  patient 
quickly  back  to  a normal  state  of  nutrition. 

1 Formulas  for  the  preparation  of  these  foods  will  be  found  under 
Dietary,  p.  452. 

16 


242 


OBSTETRIC  COMPLICATIONS 


Prevention  of  Decubitus. — The  sacrum  and  bony 
prominences  must  be  inspected  several  times  daily  and 
an  incipient  bed-sore  treated  at  once.  Frequent  change 
of  position,  the  use  of  air-cushions,  an  invalid  bed,  and 
absolute  cleanliness  will  prevent  decubitus.  Daily  wash- 
ings with  25  per  cent,  alcohol,  followed  by  a gentle  rub- 
bing with  sterile  olive  oil,  will  aid  in  prevention. 

The  mouth  in  cases  of  hyper  emesis  becomes  reddened, 
tender,  often  bleeding,  and  teeth  and  lips  accumulate 
sordes.  If  the  patient  becomes  delirious,  the  resem- 
blance to  a typhoid  case  is  striking.  The  nurse  cleans 
the  tongue  and  gums  carefully  (as  the  mucous  membrane 
is  easily  scratched)  with  boric  acid  solution  containing  3 
per  cent,  lemon-juice.  No  brush  may  be  used  on  the 
teeth.  The  finger  is  covered  with  a napkin  or  pledget 
and  is  gently  rubbed  over  them.  Care  is  to  be  taken  to 
prevent  the  patient  from  gagging.  Throughout  such  a 
case  the  nurse  should  see  that  the  patient  gets  sleep, 
here,  without  doubt,  nature’s  sweetest  restorer. 

Toxemia  in  Pregnancy.  -Closely  allied  to  hyper- 
emesis gravidarum  is  the  toxemia  of  pregnancy.  By  this 
is  meant  that  poisonous  products  (toxins)  have  accumu- 
lated in  the  blood.  During  pregnancy  the  general 
chemic  changes  going  on  in  the  woman’s  body  are  more 
active,  and,  in  addition,  there  is  an  increase  of  waste 
matter — that  produced  by  the  child.  Should  the 
mother’s  liver  or  her  kidneys,  or  both,  be  unable  to 
handle  and  excrete  these  waste-products,  they  accumu- 
late as  toxins  in  the  blood,  producing  toxemia.  This  is 
a dangerous  condition  and  requires  active  treatment  by 
the  physician. 

The  symptoms  are  headache,  dizziness,  cloudiness  of 
mind  and  of  vision,  dry,  muddy  skin,  deficient  urination 
(the  urine  is  high  colored  and  strong),  constipation, 
brown,  furred  tongue,  etc. 


VARICOSE  VEINS 


243 


The  physician  treats  these  cases  by  restricting  the 
patient  to  a milk  diet  for  a while,  and  then,  as  improve- 
ment appears,  cereals  are  given,  and  then  a vegetarian 
diet.  At  the  same  time  saline  cathartics  are  administered 
and  warm  baths — in  urgent  cases,  the  hot  pack.  Unless 
successfully  treated,  toxemia  may  result  in  eclampsia. 

Edema  of  the  Extremities.— Frequently,  late  in 
pregnancy  the  feet  swell  up,  becoming  dropsical.  The 


Fig.  126. — Varicose  veins  of  the  lower  extremity  in  a pregnant  woman  at  term 

(Hirst). 

symptom  is  usually  unimportant,  but  it  should  be  re- 
ported to  the  physician.  The  edema  is  due  to  mechan- 
ical obstruction  to  the  return  flow  of  the  blood,  but  it 
may  indicate  disease  of  the  kidneys,  Bright’s  disease,  or 
heart  disease,  and  will  be  the  cause  of  earnest  solicitude 
to  the  doctor. 

Varicose  Veins. — Varicosities  of  the  veins  in  the 
legs  and  around  the  vulva  are  quite  common  in  advanced 


244 


OBSTE  TRIC  COMPL ICA  T/ONS 


pregnancy  in  multipart.  Primiparae  and  women  who 
take  good  care  of  themselves  are  less  troubled  with 


Fig.  127. — The  treatment  of  varicose  veins  by  means  of  strips  of  adhesive  plaster. 
Seldom  necessary  to  cover  the  whole  limb. 


them.  In  some  cases  the  enlargement  of  the  veins  is  so 
great  as  to  cause  real  distress,  as  burning,  itching,  and 
pain  in  the  legs  and  lower  pelvis  (Fig.  126). 


PRURITUS 


245 


The  treatment  consists  in  the  institution  of  a hygienic 
mode  of  life,  as  given  under  Hygiene  of  Pregnancy  (p. 
75).  There  should  be  no  circular  constriction  at  any 
part  of  the  body,  especially  no  round  garters,  corsets, 
or  tight  waistbands.  The  return  of  blood  to  the  heart 
must  be  unhindered. 

The  feet  must  be  kept  off  the  floor  as  much  as  possi- 
ble, and  rubber  stockings  or  a flannel  bandage  worn 
during  the  day.  A flannel  bandage  does  not  do  any 
good  unless  well  applied  and  kept  in  place.  Adhe- 
sive plasters  give  considerable  relief  in  these  cases. 
Strips  are  cut  1 inch  wide  and  7 inches  long  These  are 
placed  in  a spiral  direction  partly  around  the  leg  be- 
low and  over  the  largest  varicosities  (Fig  127).  These 
strips  support  the  column  of  blood  in  the  veins.  They 
are  applied  while  the  patient  is  recumbent.  The  woman 
should  be  cautioned  against  injuring  the  enlarged  vessels 
by  scratching  or  striking  against  objects,  as  dangerous 
and  even  fatal  hemorrhage  has  resulted.  The  patient  is 
instructed  that  should  such  a hemorrhage  occur,  she 
should  apply  firm  pressure  to  the  bleeding  point  and 
notify  her  physician  without  a moment’s  delay. 

I^eukorrhea.  During  the  first  months  of  pregnancy 
there  is  a slight  increase  in  the  vaginal  discharge,  and 
toward  the  end  also.  No  treatment  is  required.  If  the 
discharge  is  profuse,  especially  if  yellow  or  greenish,  the 
physician  ought  to  be  consulted,  as  an  infection  of  the 
genitals  may  exist  which  may  endanger  the  patient’s 
health  and  the  baby’s  eyes.  Douches  should  not  be 
given  without  the  physician’s  order.  Leukorrhea  may 
be  caused  by  pelvic  congestion,  evidenced  by  large 
varicosities. 

Pruritus,  or  itching  of  the  pudenda,  is  sometimes  a 
very  trying  symptom.  Without  visible  lesion  of  the 
parts  the  patient  is  annoyed  by  a more  or  less  intense 


246 


OBSTETRIC  COMPLICATIONS 


itching  of  the  vulva.  This  may  be  general  over  all  the 
body.  It  may  be  so  intense  that  the  woman  loses  sleep, 
and  it  becomes,  in  very  rare  instances,  unless  relieved,  a 
condition  dangerous  to  life.  In  these  cases  a nervous 
element  is  present.  The  physician  will  lay  out  a course 
of  treatment,  but  the  nurse  may  use  household  remedies, 


Fig.  128. — Position  of  the  child  and  the  uterus  in  a case  of  pendulous  abdomen 
(Dickinson). 

such  as  bathing  with  washing-soda  solution,  weak  car- 
bolic solution,  peppermint-water,  etc. 

If  dependent  on  an  irritating  vaginal  discharge  or  on 
“ thrush,”  which  sometimes  occurs,  appropriate  treat- 
ment is  instituted. 

Pendulous  Abdomen. — This  condition,  called  “rup- 
ture” by  the  laity,  is  produced  by  a weakening  of  the 
abdominal  wall  or  even  a separation  of  the  muscles, 


/ 


PAINS  IN  THE  A PH  OMEN 


247 


allowing  the  uterus  to  fall  far  forward  (Fig.  128)  or  even 
hang  down  between  the  knees.  It  causes  drawing  sensa- 
tions in  the  abdomen,  pain  in  the  back,  frequent  urina- 
tion, and  discomfort  in  walking  Relief  may  be  obtained 
by  supporting  the  uterine  tumor  with  an  abdominal 
binder  (Figs.  37,  38)  or  sling 
hanging  from  the  shoulder. 

The  knee-chest  position  aids 
a little  too  in  relieving  the 
symptoms.  Pendulous  ab- 
domen in  a primipara  in- 
dicates that  something  is 
wrong.  It  may  render  labor 
difficult.  To  a certain  ex- 
tent it  is  preventable.  (See 
p.  78.)  The  jockey  strap  or 
combination  binder  shown 
in  Fig.  129  aids  in  its  pre- 
vention. It  is  worn  for  a 
month  or  more  after  getting 
up  from  the  puerperium. 

Pains  in  the  Abdomen. 

— Many  women  complain  of 
pains  in  various  parts  of  the 
abdomen.  These  are  due  to 
intestinal  colic,  impaction 
of  feces,  appendicitis,  trac- 
tion on  adhesions,  stretch- 
ing of  the  abdominal  wall, 

wearing  of  corsets  or  tight  waistbands,  carrying  infants 
on  the  uterine  prominence,  and  varicose  veins  in  the 
pelvis.  With  the  cause,  the  nurse  will  find  the  remedy. 
The  knee-chest  posture  will  relieve  pressure  symptoms; 
laxatives  are  exhibited,  and  hot  camphorated  oil, 
chloroform,  or  other  liniment  applied  to  the  skin.  If 


Fig.  129. — Combination  binder  or 
jockey  strap  applied. 


248 


OBSTETRIC  COMPLICATIONS 


marked  and  constant,  the  physician  ought  to  be  in- 
formed of  it. 

Heart -burn.  Indigestion  and  heart-burn  are  fre- 
quent and  annoying  symptoms  in  pregnancy.  The 
physician  will  prescribe  the  usual  remedies.  Home 
remedies  that  give  relief  are:  soda-mint  tablets,  1 to  3 
dissolved  in  the  mouth,  salted  nuts  chewed  fine,  and 
milk  of  magnesia,  1 to  3 dessertspoonfuls,  as  needed. 
Sometimes  the  stomach  must  be  washed  to  afford 
relief. 

The  teeth  in  some  patients  show  a tendency  to 
decay.  Cavities  should  be  filled  and  bad  teeth  extracted 
as  in  the  non-pregnant  state,  but  long,  tiring  gold  fillings 
and  bridge  work  should  be  postponed.  Milk  of  mag- 
nesia held  in  the  mouth  for  three  minutes  three  times  a 
day  will  relieve  the  acidity  of  the  saliva  and  help  pre- 
serve the  teeth. 

Frequent  Urination.  In  the  first  few  months  this 
is  a common  symptom.  It  passes  away,  to  return  again 
when  the  head  sinks  in  the  pelvis  at  the  time  of  lighten- 
ing. If  the  condition  is  aggravated,  destroying  the 
patient’s  peace  by  day  and  her  rest  by  night,  the  physician 
should  be  consulted.  It  is  sometimes  due  to  the  uterus 
being  turned  back  and  imprisoned  in  the  pelvis,  the  mal- 
position distorting  and  compressing  the  urethra.  The 
bladder  fills  almost  to  bursting  and  then  overflows 
(ischuria  paradoxa).  The  catheter  should  always  be 
used  to  aid  the  diagnosis,  but  extreme  care  should  be 
taken  not  to  injure  the  urethra  by  making  a false  passage. 
Cystitis  and  ureteritis  may  occur.  If  there  is  no  path- 
ologic basis  for  the  frequent  urination,  the  knee-chest 
posture  will  relieve  the  discomfort  somewhat. 

Fainting-. — Some  women  are  much  annoyed  by  this 
condition.  Without  apparent  cause,  or  on  the  occasion 
of  a little  excitement,  or  by  being  in  a close  room,  the 


HEMORRHAGE  DURING  PREGNANCY  249 

gravida  feels  faint,  and  may  even  fall  to  the  ground.  In 
a few  moments  the  attack  has  passed. 

The  writer  has  observed  this  condition.  It  is  not  a real 
faint,  as  the  pulse  is  good,  and  the  face  only  slightly  paled, 
though  in  some  instances  it  may  be  an  actual  fainting. 
Consciousness  is  not  lost.  One  must  be  sure  that  there 
is  no  real  heart  disease  present. 

This  symptom  may  be  present  from  the  fourth  month ; 
it  does  not  influence  the  pregnancy,  though  most  distress- 
ing to  the  patient.  The  diet  should  be  regulated — non- 
nitrogenous;  the  excretions  should  be  stimulated;  the 
patient  should  avoid  crowds,  excitement,  and  irrational 
dress.  The  harmlessness  of  the  condition  should  be 
explained  to  her  to  allay  the  alarm  it  naturally  causes. 
The  physician  occasionally  prescribes  a tonic. 

Melancholia. — Some  women,  especially  if  from  a 
neurotic  family  and  of  neurotic  tendency,  anticipate  their 
coming  confinement  with  increasing  dread.  While  most 
women  at  some  time  or  other  during  pregnancy  imagine 
they  are  going  to  die  before  they  are  through  with  it, 
these  patients  develop  an  actual  idea,  a fixed  fear,  of 
death,  and  thus  the  border-line  of  insanity  is  reached. 
The  general  symptoms  of  melancholia  may  appear.  The 
writer  has  noticed  an  apparent  relation  between  this  ner- 
vous condition  and  the  toxemia  described  in  this  chapter. 
The  nurse  may  do  much  by  a cheerful  bearing  and  re- 
assurances to  allay  unnatural  alarms  in  the  patient,  but 
the  physician  should  be  consulted  if  the  condition  is  at 
all  pronounced. 

Hemorrhages  During  Pregnancy. — The  whole 
reproductive  cycle  is  attended  with  the  possibility  of 
hemorrhage  from  the  genitals.  In  the  early  months 
abortion  may  be  the  cause  of  the  hemorrhage. 

Abortion. — This  means  the  interruption  of  pregnancy 
before  the  seventh  month.  The  child  is  not  viable  before 


250 


OBSTE  TRIC  COM  PLICA  TIONS 


the  twenty-eighth  week.  The  symptoms  of  abortion 
are  bleeding  from  the  uterus  and  pains — miniature  labor 
pains. 

The  nurse,  finding  the  woman  with  threatened  abor- 
tion, should  put  her  to  bed  and  send  for  her  physician. 
If  the  woman  is  bleeding  too  profusely,  she  should,  while 
waiting  for  him,  pack  the  vagina  as  tightly  as  she  can 
with  sterile  cotton,  under  the  usual  asepsis,  or  send  for 
the  nearest  doctor.  Then  she  should  prepare  every- 
thing for  operation,  so  as  to  avoid  delays  when  the  phys- 
ician arrives. 

Placenta  Praevia. — This  is  the  development  of  the 
placenta,  in  part  or  in  toto,  in  the  lower  uterine  segment. 
Thus  a portion  of  the  placenta  comes  to  lie  over  the  in- 
ternal os,  in  the  way  of  the  child,  and  thus  the  name 
“praevia”  (Fig.  130). 

The  placenta  is  usually  located  near  the  top  of  the 
uterus,  out  of  the  way  of  harm,  but  when  it  is  placed 
near  the  cervix — that  is,  in  placenta  praevia — it  is  loos- 
ened from  its  attachment  when  the  os  begins  to  dilate, 
thus  causing  hemorrhage.  The  condition  is  serious, 
published  statistics  giving  a maternal  death-rate  of  from 
10  to  38  per  cent.,  and  a fetal  death-rate  of  50  per  cent. 

If  a woman  has  one,  and  especially  if  she  has  more 
than  one,  uterine  hemorrhage  in  the  latter  half  of  the 
pregnancy,  it  is  usually  due  to  placenta  praevia.  Of 
course,  if  a woman  bleeds  from  hemorrhoids,  it  is  not  in 
this  category.  A painless,  causeless  uterine  hemorrhage 
in  the  last  three  months  of  pregnancy  means  almost  al- 
ways placenta  praevia. 

The  nurse  must  notify  the  physician  at  once  if  there 
is,  during  pregnancy,  the  slightest  show  of  blood.  If  she 
is  the  only  one  present  during  a severe  bleeding,  to  tam- 
pon the  vagina  and  to  elevate  the  foot  of  the  bed  would 
be  her  only  recourse. 


HEMORRHAGE  DURING  PREGNANCY 


251 


Premature  Detachment  of  the  Placenta.  — This  means 
the  dislocation  of  the  placenta  from  its  normal  site.  It 
is  sometimes  called  abruptio  placentae,  meaning  that  the 
placenta  is  torn  from  its  bed.  It  is  a very  rare  and  very 
fatal  accident,  50  per  cent,  of  the  mothers  and  nearly  all 


Fig.  130. — Central  placenta  praevia,  the  os  partly  dilated  (Hunter). 


the  children  being  lost.  It  is  usually  due  to  injury,  the 
patient  hitting  against  the  corner  of  a table  or  being 
struck  on  the  abdomen.  The  symptoms  are  those  of 
internal  hemorrhage — pallor,  fainting,  weak  pulse,  etc. 
The  hemorrhage  may  be  external  too. 

The  nurse’s  duties  in  the  last  two  complications  will 


252 


OBS  TE  TR/C  COMPL ICA  TIONS 


be  to  prepare  for  delivery,  for  the  application  of  a col- 
peurynter,  tamponade,  or  even  cesarean  section. 

Extra-uterine  Pregnancy.  -Extra-uterine  preg- 
nancy, or  ectopic  gestation,  is  a rare  condition,  though, 
since  its  recognition  has  become  easier,  it  is  found  more 
frequently  than  in  the  olden  time.  It  is  the  development 
of  the  pregnancy  outside  the  uterine  cavity.  Normally 
the  ovum  passes  down  the  fallopian  tube  into  the  cavity 
of  the  uterus,  pursuing  its  further  development  there. 
If,  however,  it  is  arrested  in  the  tube  and  grows  here, 


Fig.  13 1. — Extra-uterine  (tubal)  pregnancy,  before  rupture  of  the  sac. 


an  ectopic  gestation  of  the  tubal  variety  results.  The 
tubal  is  the  common  form  of  the  anomaly,  but  the  child 
may  develop  in  the  ovary  or  even  in  the  abdomen. 

Extra-uterine  pregnancy  is  a serious  condition,  though 
in  a few  cases  a spontaneous  cure  results.  The  ac- 
coucheur does  not  wait  for  this,  but  considers  almost 
every  case  an  indication  for  immediate  operation. 

In  those  cases  where  spontaneous  cure  occurs,  the 
ovum  is  either  discharged  from  its  bed  and  absorbed,  or, 
if  the  child  has  attained  considerable  size,  labor  comes  on, 


EXTRA-  UTERINE  ERE  GNANC  Y 


253 


without,  of  course,  the  delivery  of  the  fetus.  The  child 
dies  and  either  is  changed  into  a hard,  chalky  mass,  called 
a lithopedion,  or  stone-child,  in  which  condition  it  may 
remain  for  years;  or  the  whole  ovum  becomes  infected 
and  breaks  down  into  pus  and  necrotic  debris.  The  sac 
may  ulcerate  through  the  neighboring  structures — the 
bladder,  vagina,  rectum,  or  abdominal  wall — and  the 
bones  of  the  infant  are  discharged  thus,  one  at  a time. 
If  the  patient  survives  this  long  suppuration,  after  many 


Fig.  132. — Extra-uterine  (tubal)  pregnancy,  after  rupture  of  the  sac. 


months  the  whole  mass  is  thus  gotten  rid  of.  Most  cases 
of  ectopic  gestation  present  alarming  symptoms  between 
the  second  and  fourth  months,  due  to  rupture  of  the  tube 
and  intraperitoneal  hemorrhage,  which  necessitates  the 
accoucheur’s  interference. 

As  the  ovum  grows  it  distends  the  tube  (Fig.  13 1). 
The  fallopian  tube  has  a thin  wall,  and,  unlike  the  uterus, 
does  not  hypertrophy  to  accommodate  the  growing 


254 


OBSTE  TRIC  COMP LIC A TIONS 


ovum.  The  tube,  as  the  result  of  the  distention,  on 
the  occasion  of  a sudden  jar  to  the  abdomen,  a blow, 
straining  at  stool,  etc.,  bursts  (Fig.  132).  The  ovum  is 
wholly  or  partly  expelled  into  the  free  peritoneal  cavity, 
and  more  or  less  profuse  hemorrhage  takes  place  from  the 
walls  of  the  tube.  This  hemorrhage  may  be  mild  and  the 
patient  may  then  recover  without  treatment  (rare),  or 
the  hemorrhage  may  be  severe,  and  the  most  heroic 
measures  must  be  instituted  to  save  the  woman’s  life. 

The  cause  of  ectopic  gestation  is  usually  found  in  dis- 
ease of  the  appendages  or  congenital  anomaly.  Chronic 
tubal  inflammation  or  pelvic  peritonitis  is  usually  causa- 
tive. The  condition  may  occur  twice. 

Symptoms. — The  patient  has  the  symptoms  of  preg- 
nancy, but  menses,  in  small  amount,  may  appear,  and 
pieces  of  membrane  may  be  discharged.  In  addition, 
there  are  usually  pain  and  a sensation  of  fulness  on  the 
affected  side.  Should  such  symptoms  come  to  the 
knowledge  of  the  nurse,  she  should  advise  the  patient 
to  consult  her  doctor.  The  physician  may  discover  a 
tumor  alongside  the  uterus,  which,  taken  in  conjunction 
with  the  suspicion  of  pregnancy,  usually  leads  to  the 
diagnosis.  The  symptoms  of  rupture  are  very  promi- 
nent, though  not  always  easy  to  differentiate  from  those 
due  to  other  conditions. 

The  patient  complains  of  an  agonizing  pain  low  down 
in  the  side,  and  this  may  last  for  an  hour  or  more.  Then 
the  symptoms  of  internal  hemorrhage  and  shock  super- 
vene— nausea,  vomiting,  anxiety,  prostration,  precordial 
oppression,  pallor,  pearly  conjunctivae,  rapid  pulse, 
rapid  breathing,  and,  if  aid  is  not  given,  death  in 
collapse. 

If  the  first  hemorrhage  is  not  fatal,  the  patient  may 
have  another,  or  several.  These  are  cases  that  require 
heroic  treatment. 


EXTRA-  UTERINE  PRE  GNANC  Y 


255 


Duties  of  the  Nurse.  If  a nurse  is  placed  in  charge 
of  a case  of  extra-uterine  pregnancy  before  the  rupture 
of  the  sac,  her  main  solicitude  will  be  to  prevent  the 
rupture.  To  accomplish  this,  she  will  not  allow  the 
patient  to  turn  in  bed  without  aid ; will  not  permit  strain- 
ing during  urination  or  defecation;  and,  in  general,  will 
keep  the  patient  as  free  as  possible  from  the  slightest 
exertion.  If  the  case  is  chronic  and  the  fetus  gone  on 
to  lithopedion  formation,  these  rigorous  rules  need  not 
be  enforced,  although  the  patient  should  observe  more 
than  ordinary  care. 

In  preparing  such  a patient  for  operation,  only  the 
gentlest  manipulation  of  the  abdomen  is  permissible. 
Rough  scrubbing  might  rupture  the  sac  and  precipitate 
a fatal  hemorrhage.  The  nurse  should  acquaint  herself 
with  the  symptoms  of  rupture,  so  as  to  be  able  to  in- 
form the  accoucheur  at  the  earliest  moment.  She  should 
also  obtain  from  him  concise  instructions  regarding  what 
he  wishes  her  to  do  in  the  emergency  As  soon  as  the 
nurse  takes  charge  of  such  a case,  she  should  begin  to 
prepare  for  the  operation,  which  usually  is  not  long  de- 
layed. In  a quiet,  unostentatious  manner,  the  nurse 
may  provide  and  sterilize  all  the  utensils,  linen,  gauze, 
etc.,  necessary  for  abdominal  section.  Each  night  io 
gallons  of  water  should  be  boiled  and  set  away  to  cool. 
If  not  used,  it  is  thrown  away.  Thus  the  nurse  is  pre- 
pared for  all  emergencies.  Half  the  battle  is  already 
wron  by  efficient  preparation. 

Should  the  nurse  diagnose  the  bursting  of  the  sac  and 
the  occurrence  of  intra-abdominal  hemorrhage,  she 
should  elevate  the  foot  of  the  bed,  apply  a tight  ab- 
dominal binder,  and  put  an  ice-bag  on  the  abdomen. 
The  physician  should  at  once  be  notified;  if  he  is  not 
within  call,  one  of  his  close  associates;  or,  failing  these, 
the  nearest  doctor.  While  waiting  for  aid,  the  nurse 


256 


OBS  TE  TRIC  COMPL ICA  TIONS 


prepares  the  room  for  operation  (see  p.  183),  provides  an 
abundance  of  sterile  water,  salt  solution  (0.7  per  cent.), 
sterile  sheets,  towels,  pitchers,  basins,  etc.  Laparotomy 
will  usually  have  to  be  done,  and  a good  nurse  will  have 
saved  much  time  in  getting  ready  for  it  beforehand. 
The  preparations  and  instruments  are  the  same  as  for 
cesarean  section. 

The  after-care  is  that  usual  for  laparotomies  (see  p. 
209)  plus  extra  effort  to  replace  the  blood  the  patient  has 
lost.  To  accomplish  this,  saline  solution  is  given  by 
hypodermoclysis  and  by  rectum.  Nourishing  foods  and 
tonics  are  administered,  general  massage,  fresh  air,  and 
the  best  hygienic  measures  are  practised.  (See  Treat- 
ment of  Hemorrhage,  p.  277.) 

Eclampsia.  The  word  “eclampsia”  means  to  flash 
out,  and  has  reference  to  the  suddenness  of  the  onset  of 
the  disease.  Eclampsia  is  the  occurrence  of  convulsions 
followed  by  coma  during  pregnancy,  labor,  or  the  puer- 
perium.  The  acting  causes  of  eclampsia  are  unknown. 
It  is  supposed  that  the  convulsions  and  coma  are  due  to 
a poisoning  of  the  blood — a toxemia.  This  toxemia 
may  be  caused  by  inefficient  action  of  the  liver,  insuffi- 
cient elimination  by  the  kidneys,  improper  processes 
going  on  in  the  placenta,  imperfect  chemic  changes  in 
the  intestines,  etc.  There  may  be  truth  in  all  these 
theories.  It  is  certain  that  there  are  many  varieties  of 
toxemia,  and  not  all  produce  convulsions.  No  matter 
what  the  primary  cause,  the  kidneys  are  usually  involved. 
There  are  almost  always  evidences  of  a more  or  less 
acute  nephritis. 

Symptoms.  -Usually  there  are  prodromal  or  premoni- 
tory signs  of  the  trouble  for  a few  days.  The  patient 
has  headache,  ocular  disturbance,  spots  before  the  eyes, 
twitching  of  the  muscles  of  the  calves  or  of  the  face,  a 
boring  pain  in  the  epigastrium,  vomiting,  ringing  in  the 


ECLAMPSIA 


25  7 


ears,  etc.  Sometimes  there  is  a tendency  to  coma,  and 
these  are  the  worst  cases.  At  times  there  is  extensive 
edema  of  the  feet. 

Suddenly  the  patient  falls  down  unconscious  and  in  a 
convulsion.  The  mouth  is  drawn  to  the  side,  the  facial 
muscles  twitch,  then  the  arm,  next  the  leg,  then  the 
whole  body  is  shaken  violently  by  strong  muscular 
spasms.  The  patient  may  bite  the  tongue  severely  and 
bloody  foam  appears  on  the  lips.  This  part  of  the  spasm 
is  succeeded  by  a period  of  rigidity.  The  patient  is  stiff, 
the  respiration  ceases,  and  the  body  becomes  cyanotic. 
The  heart  beats  violently  and  then  weakens,  and  the 
patient  may  die  in  such  a convulsion.  Though  it  seems 
much  longer,  the  spasm  seldom  lasts  more  than  sixty 
seconds,  and  at  the  end  the  patient  takes  a long  inspira- 
tion The  breathing  now  becomes  stertorous  or  snoring, 
the  cyanosis  mostly  disappears,  and  the  patient  lies  in 
deep  coma.  This  coma  may  last  an  hour  or  longer. 
Another  convulsion  may  occur  in  twenty  minutes  to  a 
few  hours,  or  there  may  be  only  one,  or  the  seizures  may 
recur  the  next  day.  The  greater  the  number  of  convul- 
sions, the  greater  is  the  danger.  Deep  coma  and  great 
cyanosis  likewise  give  a gloomy  outlook. 

If  the  patient  has  a strong  regular  pulse,  running  not 
over  no,  with  red  face  (not  cyanosis),  the  promise  is 
good  for  recovery.  If  she  develops  edema  of  the  lungs, 
death  almost  always  results. 

Treatment.  -The  nurse  must  report  to  the  physician 
at  once  if  she  finds  albumin  in  the  urine  at  any  of  her 
analyses  or  if  the  patient  presents  any  of  the  prodromal 
symptoms  mentioned.  Taken  in  time,  one  can  usually 
prevent  the  convulsions,  which  is  a great  feat,  since  the 
mortality  of  eclampsia  is  about  25  per  cent.  The  patient 
is  put  at  once  on  an  absolute  milk  and  water  diet,  and 
may  be  given  sedatives  by  the  physician.  The  bowels, 
17 


258 


OB S TE  TR/C  CO MPL ICA  TIONS 


kidneys,  and  skin  are  stimulated  to  action,  Unless  the 
symptoms  disappear  rapidly,  labor  is  brought  on. 

If  the  convulsions  have  set  in  or  are  imminent,  the 
nurse  should  prevent  the  patient  from  injuring  herself. 
She  must  be  placed  in  bed,  with  many  soft  pillows,  and 
her  dress  removed.  The  patient  must  not  be  left  alone 
one  minute.  The  room  must  be  darkened,  and  all  noises 
shut  out.  No  talking , jarring  the  bed , or  slamming  of  the 
doors  may  be  permitted.  Only  the  nurse  and  the  phys- 
ician should  be  with  the  patient.  Great  care  must  be 
taken  that  the  patient  does  not  bite  her  tongue ; this  is  a 
real  danger.  If  the  patient  has  false  teeth,  they  should 
be  removed;  if  bridge  work  or  crowns,  the  nurse  takes 
care  that  they  are  not  broken.  The  best  method  of  pre- 
venting injury  to  the  teeth  is  by  means  of  an  ordinary 
wooden  clothes-pin  (Fig.  133).  This  is  covered  with  a 
piece  of  gauze  sewed  on  tightly,  a string  is  tied  to  it, 
and  it  is  hung  near  the  head  of  the  bed,  within  easy  reach 
all  the  time.  When  the  patient  opens  her  mouth,  as  is 
usual  at  the  beginning  of  the  convulsion,  the  clothes-pin 
is  placed  between  the  jaws,  so  that  when  the  muscles 
contract  they  bring  the  teeth  together  on  the  prongs  of 
the  pin,  the  elasticity  of  the  prongs  preventing  injury  to 
the  teeth,  jaws,  and  tongue.  The  nurse  now  prepares 
everything  for  the  doctor’s  coming  and  for  operation. 

During  the  progress  of  the  case  the  patient  may  have 
had  cathartics,  and,  being  comatose,  the  movements 
occur  in  the  bed.  When  changing  the  patient,  great  care 
must  be  taken  to  prevent  infection  of  the  vulva,  and  also 
to  avoid  jarring  her  too  much,  because  it  sometimes 
brings  on  convulsions. 

Sometimes  the  patient  is  given  hot  packs  to  promote 
diaphoresis,  and  thus  excretion  of  toxins  by  the  skin. 
The  nurse  must  not  allow  a hot  pack  to  last  over  twenty 
minutes;  she  must  keep  an  ice-bag  on  the  head  or  a cold 


ECLAMPSIA 


259 


wet  towel  around  the  neck,  and  she  must  watch  the  pa- 
tient continually,  because  sometimes  death  occurs  dur- 
ing the  sweating  process.  If  bricks  or  hot  irons  are  used 
for  the  hot  pack,  the  nurse  must  see  that  they  do  not 
burn  the  patient.  In  her  tossing  about  and  in  the  con- 
vulsions the  patient  displaces  the  blankets;  severe 
burns  have  thus  been  caused.  When  the  pack  is  re- 
moved, great  care  is  to  be  taken  to  avoid  chilling. 


Fig.  133. — Prevention  of  tongue  injuries  by  means  of  the  clothes-pin.  The 
covered  clothes-pin  is  the  one  used.  Photograph  of  eclampsia  case  taken 
during  the  stage  of  stertorous  breathing.  Note  swollen  tongue. 

Oxygen  may  be  given,  and  salt  solution  by  hypoder- 
moclysis.  When  narcotics — morphin,  chloral,  etc. — are 
given,  the  nurse  must  watch  the  effect  of  these  drugs, 
because  they  may  act  with  unusual  strength.  All  these 
medicines  and  all  the  treatments,  the  number  of  convul- 
sions, and  condition  of  the  patient  should  be  recorded 
carefully  on  the  history-sheet.  Altogether,  nursing  an 


26o 


OBSTETRIC  COMPLICATIONS 


eclampsia  case  requires  the  highest  kind  of  obstetric 
nursing  skill. 

No  nourishment  is  given  until  the  patient  can  swallow, 
unless  by  stomach-tube,  and  throughout  the  nurse  must 
exercise  great  vigilance  to  prevent  water,  medicine, 


Fig.  134. — Treatment  of  edema  of  the  lungs.  Head  is  supported,  and  the 
nurse  raises  the  shoulder  so  as  to  allow  free  expansion  of  the  chest. 


mucus,  and  blood  from  the  mouth  and  throat  being 
drawn  into  the  lungs.  This  is  a serious  affair,  causing 
bronchopneumonia  and  often  death.  If  the  patient 
develops  edema  of  the  lungs,  the  nurse  turns  her  on  the 
side  with  the  head  hanging  over  the  edge  of  the  bed,  so 
as  to  allow  the  frothy  mucus  to  run  out  of  the  mouth 


ECLAMPSIA 


26l 

(Fig.  134).  The  shoulder  must  be  supported  or  the 
patient’s  breathing  will  be  interfered  with.  If  the 
tongue  of  a comatose  patient  falls  back  into  the  throat, 
asphyctic  conditions  may  arise.  The  jaw  should  then 
be  held  forward  to  free  the  respiration.  Eclampsia  is 
an  awe-inspiring  condition,  and  the  patient’s  life,  as  well 
as  that  of  her  child,  often  depends  on  the  coolness  and 
judgment  of  their  attendants. 

Recovery  from  eclampsia  takes  place  slowly.  The 
coma  disappears  in  from  one  to  four  days. 

The  child  is  not  to  be  allowed  to  nurse  till  conscious- 
ness has  been  clear  for  several  days.  The  mother  may 
repudiate  her  own  child,  which  should  give  rise  to  the 
suspicion  that  insanity  is  threatening.  Mental  aberra- 
tion is  a not  uncommon  sequel  of  eclampsia. 


CHAPTER  II 


COMPLICATIONS  DURING  LABOR 

The  most  common  complication  which  the  nurse  will 
meet  is  delivery  of  the  child  before  the  doctor  comes. 
The  physician  is  usually  quite  chagrined  if  the  baby 
arrives  before  he  does.  How  much  the  nurse  may 
retard  the  delivery  so  as  to  await  the  doctor  is  an  im- 
portant question.  If  the  patient  is  having  strong  pains, 
the  nurse  should  keep  her  on  her  side  and  not  allow  her 
to  bear  down.  The  nurse  should  know  the  doctor’s 
practice,  what  physicians  usually  assist  him,  and,  if  the 
accoucheur  is  not  obtainable,  should  send  for  one  of  the 
men  known  to  him,  unless  the  family  expresses  other 
preference.  It  is  not  advisable  for  the  nurse  to  assume 
the  responsibility  of  the  case  alone.  While  generally 
there  is  no  danger,  it  may  be  her  lot  to  lose  an  infant, 
and  thus  she  may  be  unfairly  censured.  It  is  not  justi- 
fiable for  the  nurse  to  hold  the  head  back  forcibly  until 
the  doctor  comes.  She  may  hold  it  back  so  as  to  allow 
time  for  the  perineum  to  stretch,  as  she  has  seen  the 
doctor  do,  but  more  than  this  may  injure  the  child  or 
the  mother.  If  she  has  to  conduct  the  labor,  let  her 
observe  the  same  rules  regarding  protection  of  the  peri- 
neum as  those  practised  by  the  physician: 

1.  Allow  the  head  to  come  through  slowly. 

2.  Keep  the  head  well  flexed  and  against  the  pubic 
arch. 

3.  Deliver  the  patient  on  the  side. 

4.  Deliver  the  head  between  pains. 

262 


COMPLICATIONS  DURING  LABOR  263 

When  the  nurse  finds  she  is  alone  with  the  case,  she 
should  allay  the  fears  of  the  family  by  telling  them  that 
the  fact  that  the  child  is  coming  so  quickly  is  proof  that 
everything  is  right  and  the  labor  is  normal. 

She  places  the  patient  on  the  left  side  and  toward  the 
light,  and,  after  sterilizing  her  hands,  puts  on  her  steril- 
ized gloves,  assumes  the  position  the  doctor  would,  with 
one  hand  between  the  limbs  of  the  patient,  whose  knees 
are  separated  by  a pillow.  (See  Fig.  61.)  A basin  of 
solution  with  pledgets  is  nearby,  and  the  nurse  carefully 
catches  any  discharges  from  the  rectum  without  soiling 
her  fingers.  She  also  swabs  the  parts  generously  with  the 
antiseptic  solution.  Lysol,  1 per  cent.,  is  good,  or  1 : 1500 
bichlorid.  As  the  perineum  bulges  and  the  scalp  shows 
she  gently  restrains  the  head  by  pressure  on  it  with  the 
fingers,  not  by  pressure  on  the  perineum.  With  each 
pain  she  allows  the  head  to  come  down  a little  more. 
The  patient  should  be  admonished  not  to  bear  down  too 
hard,  and  thus  the  nurse  will  allow  the  head  to  come 
through  very  slowly.  After  the  perineum  is  stretched  so 
that  it  seems  as  if  the  head  may  come  through,  in  the 
interval  between  pains  the  patient  is  asked  to  bear  down 
a little  and  the  head  will  come.  After  a few  moments 
the  pains  force  the  shoulders  out  and  then  the  trunk  fol- 
lows. (See  Figs.  135-141.) 

When  the  head  is  born,  the  nurse  wipes  mucus  from 
the  head  and  eyes  and  from  the  nose  and  mouth,  so  that 
when  the  child  gasps,  nothing  can  be  drawn  into  the 
lungs.  After  the  child  is  born,  the  nurse  playes  it  a short 
distance  from  the  mother,  so  that  she  cannot  press  it  or 
the  cord,  and  both  patients  are  covered  warmly.  (See  Fig. 
62.)  The  woman  is  slowly  turned  on  her  back,  keeping 
the  legs  tight  together.  The  nurse  sits  beside  the  patient, 
holding  the  uterus  with  her  hand,  but  not  massaging  it 
unless  there  is  hemorrhage  or  the  uterus  balloons  out 


264  COMPLICATIONS  DURING  LABOR 


Fig.  135. — Delivery  of  patient  on  the  side.  Nurse,  with  one  hand  between 
thighs,  gently  represses  the  head  during  the  pains.  The  right  hand  is  nearby 
to  help  hold  the  head  back  if  the  pain  is  too  strong.  The  hands  should  not 
be  soiled  with  rectal  discharges. 


Fig.  136. — The  two  hands  placed  on  the  head  (not  on  the  perineum),  with 
gentle  force,  evenly  distributed,  hold  the  head  back,  allowing  it  to  advance 
only  a very  little  with  each  pain.  The  right  hand  holds  a sponge  with  which 
the  nurse  bathes  the  vulva  as  the  head  recedes. 


DELIVERY  OF  PATIENT  ON  THE  SIDE  265 


Fig.  137. — The  nurse  allows  the  head  to  come  down  during  a pain,  controlling 
its  descent  with  the  left  hand.  The  right  hand  is  about  to  be  placed  on  the 
head  as  the  perineum  is  getting  quite  distended,  which  is  shown  by  the  shiny 
appearance  of  the  skin.  The  sponge  is  used  to  wipe  a little  mucus  from  the 
anus  which  is  being  forced  open  by  the  advancing  head. 


Fig.  138. — The  head  is  about  to  escape  from  the  vulva.  The  nurse  pushes 
it  upward  against  the  pubic  arch  with  the  right  hand,  while  the  fingers  of  the 
left  hand  try  to  strip  the  anterior  edges  of  the  vulva  back  behind  the  occiput. 
The  head  is  then  allowed  to  roll  up  over  the  pubis,  the  perineum  slipping  over 
the  child’s  face  and  under  its  chin. 


266 


COMPLICATIONS  DURING  LABOR 


Fig.  139. — The  head  is  delivered.  The  nurse  steadies  it  with  the  left  hand, 
and  wipes  eyes,  nostrils,  and  mouth  with  a sponge  squeezed  dry  from  an  anti- 
septic solution. 


Fig.  140. — The  shoulders  are  being  delivered.  The  nurse  holds  the  head 
with  the  left  hand,  and  with  the  right  she  crowds  the  shoulder  upward  toward 
the  pubis  so  as  to  avoid  too  much  distention  of  the  perineum  by  the  trunk. 
Note  how  the  occiput  has  rotated  to  the  side,  as  it  lay  in  the  uterus. 


DELIVERY  OF  PATIENT  ON  THE  SIDE  267 


under  the  hand.  In  this  position  she  should  wait  for 
the  arrival  of  the  doctor.  She  must  not  tie  and  cut  the 
cord  unless  the  mother  bleeds  or  unless  the  placenta 
comes.  She  may  wait,  in  the  absence  of  hemorrhage,  as 
above  indicated,  an  hour  or  more,  without  endangering 
the  patient  or  the  infant. 


Fig.  141. — The  child  is  delivered.  With  the  left  hand  the  nurse  grasps  the 
uterus.  With  the  right  she  lays  the  child  alongside  the  lower  thigh  of  the 
mother,  and  steadies  it  while  the  mother  is  being  turned  on  her  back.  This  is 
done  as  follows:  the  right  foot  of  the  mother,  the  upper  one,  is  removed  from 
the  pillow  and  placed  on  the  edge  of  the  bed  just  outside  the  baby’s  head. 
Then  the  left  knee  is  grasped  and  raised  in  the  air  so  that  the  patient’s  hips  are 
brought  to  the  middle  of  the  bed,  after  which  the  foot  is  placed  on  the  bed. 
The  patient  is  now  in  position  for  the  conduct  of  the  third  stage.  (See  Fig.  62.) 
When  these  photographs  were  taken  gloves  were  omitted  for  artistic  reasons. 


Should  it  be  desirable  to  separate  the  child,  the  nurse 
ties  and  cuts  the  cord  as  shown  in  Figs.  142  and  143,  tying 
tightly  and  using  sterile  tape;  then,  after  removing  the 
infant,  she  folds  a clean  sheet  under  the  patient  and 
brings  the  limbs  closely  together.  Then  the  nurse  lays 


268 


COMPLICATIONS  DURING  LABOR 


Fig.  142. — Tying  the  umbilical  cord.  The  cord  is  tied  § inch  from  the  skin 

margin. 


Fig.  143. — Cutting  the  umbilical  cord.  The  cord  is  severed  \ inch  from  the 

ligature. 


BREECH  PRESENTATION  269 

her  hand  lightly  on  the  uterus  and  awaits  the  spontane- 
ous termination  of  the  third  stage. 

Almost  always  the  physician  arrives  at  this  time,  and  if 
he  does  not,  the  nurse  pursues  the  safer  course  by  insist- 
ing that  another  be  called. 

Should  she  be  compelled  by  hemorrhage,  either  inter- 
nal or  external,  to  end  the  labor  herself,  she  expresses 
the  placenta  by  gently  squeezing  the  uterus  at  the  height 
of  an  after-pain  and  pressing  the  placenta  out  at  the  same 
time.  As  the  placenta  appears  she  grasps  it  in  the  full 
hand,  and  with  light,  even  traction  draws  the  membranes 
after  it.  Neither  haste  nor  excitement  is  necessary. 

The  placenta  must  be  saved  for  the  doctor’s  inspection, 
and  he  should  also  be  requested  to  examine  the  perineum 
for  lacerations  The  nurse  should  guard  the  uterus  for 
thirty  minutes  after  delivery  of  the  placenta,  and  if  it 
shows  a tendency  to  relax,  may  administer  a dram  of 
ergot. 

BREECH  PRESENTATION 

If  the  infant  should  come  by  the  breech,  the  nurse’s 
duties  are  more  onerous.  Fortunately,  this  accident  is 
quite  rare.  As  soon  as  the  breech  of  the  infant  ap- 
pears at  the  vulva,  the  nurse  brings  the  woman  across 
the  bed  with  her  hips  a little  over  the  edge,  and  the 
feet  supported  on  chairs.  As  the  child  emerges  she 
receives  it  in  a warm  towel  with  sterile  hands.  When 
the  shoulders  are  to  come  through,  the  patient  is  ex- 
horted to  bear  down,  and  the  husband  or  a neighbor 
makes  downward  pressure  on  the  uterus.  When  the 
arms  are  delivered  the  nurse  inserts  two  fingers  in 
the  child’s  mouth,  and,  with  the  other  hand  placed  over 
the  lower  abdomen,  makes  gentle  traction  downward 
and  out  with  the  one,  and  pressure  with  the  other,  so 
that  the  head  comes  upward  and  out.  In  this  gentle 


270 


COMPLICATIONS  DURING  LABOR 


fashion  the  head  is  delivered  (Fig.  86).  Care  is  now 
taken  to  clear  the  throat  of  mucus  and  revive  the  child 
from  the  mild  asphyxia  which  is  not  unusual.  (See 
Asphyxia,  pp.  360-364.)  The  rest  of  the  labor  is  as 
above  described. 

Should  the  case  be  a twin  labor,  the  nurse  will  wait 
for  nature  to  bring  the  second  child.  Assistance  here  is 
urgently  indicated. 

PROLAPSE  OF  THE  CORD 

Once  in  about  400  cases  the  umbilical  cord  prolapses 
and  appears  at  the  vulva.  This  is  a very  serious  acci- 
dent for  the  child,  since  many  times  the  infant  is  thus  lost 
by  compression  of  the  cord  and  the  resulting  asphyxia. 
For  the  mother,  it  is  not  dangerous  unless  operations  are 
undertaken  to  save  the  child. 


Fig.  144. — The  elevated  Sims  position. 


The  nurse  will  easily  recognize  the  cord  when  it  appears 
at  the  vulva,  and  must  send  for  the  physician  without  an 
instant’s  delay.  While  waiting  for  him,  she  places  the 
patient  in  the  knee-chest  position  (Fig.  124),  and,  with 
sterile  fingers,  pushes  the  cord  back  into  the  vagina 
after  washing  it  with  warm  antiseptic  solution.  The 
cord  is  retained  in  the  vagina  by  a pledget  of  cotton, 


Fig.  145. — The  Trendelenburg  posture  in  bed,  using  a chair  to  elevate  the  pelvis. 


PROLAPSE  OF  THE  CORD 


271 


or  the  nurse  holds  the  vulva  together;  under  no  con- 
dition should  the  cord  be  allowed  to  lie  outside  exposed. 


The  patient  quickly  tires  of  the  knee-chest  position,  and 
the  nurse  then  allows  her  to  fall  slowly  onto  two  pillows 
on  her  side,  in  the  elevated  Sims  position  (Fig.  144). 


2J2 


COMPLICATIONS  DURING  LABOR 


Preparations  for  operation  should  now  be  made,  as 
the  physician,  when  he  comes,  will  wish  to  make  an 
attempt  to  save  the  child’s  life.  He  may  order  the 
Trendelenburg  posture  for  the  patient,  which  the  nurse 
obtains  by  putting  a chair,  inverted,  in  the  bed,  padding 
it  with  thin  pillows,  and  arranging  the  person  on  it  as 
shown  in  Fig.  145.  Usually  patients  complain  of  dysp- 
nea and  distress  when  kept  in  the  knee-chest  and 
Trendelenburg  postures  for  any  length  of  time,  so  that 
in  such  cases  the  elevated  Sims  position  is  preferable,  as 
it  is  more  comfortable. 

Various  complications,  described  under  those  of  preg- 
nancy, may  first  appear  during  labor ; such  are  eclampsia, 
placenta  praevia,  and  detachment  of  the  placenta. 

HEMORRHAGE  DURING  LABOR 

A woman  may  have  an  unusually  bloody  “show”;  she 
may  have  a little  hemorrhage  when  the  cervix  is  dilating, 
toward  the  completion  of  the  dilatation,  due  to  slight 
tearing  of  the  cervix  As  the  head  is  being  delivered, 
there  is  not  seldom  bleeding  from  the  tearing  perineum 
or  clitoris.  Placenta  praevia  and  detachment  of  the 
placenta  occur  sometimes  during  labor,  and  give  rise  to 
profuse  and  often  dangerous  bleeding.  After  the  baby 
is  born  the  patient  may  bleed  more  or  less  profusely. 
This  last  form  of  hemorrhage  we  term 

Postpartum  Hemorrhage.  We  designate  all  bleed- 
ing after  the  child  is  born  postpartum  hemorrhage, 
although,  strictly  speaking,  the  term  should  apply  only 
after  the  placenta  is  delivered.  The  laity  call  such  loss 
of  blood  a “flooding,”  and  truly  the  appellation  is  some- 
times deserved. 

Postpartum  hemorrhage  is  caused  either  by  a lacera- 
tion of  some  part  of  the  genital  tract  or  from  atony  of 
the  uterus.  The  laceration  is  usually  made  by  an 


POSTPARTUM  HEMORRHAGE 


273 


operative  labor,  as  forceps  or  breech  extraction,  but  it 
may  occur,  although  rarely,  in  spontaneous  delivery. 
Atony  of  the  uterus  is  rare,  and  may  be  caused  by 
general  weakness  of  the  mother,  retention  in  the  uterus 
of  a piece  of  placenta  or  of  clots,  after  overdistention  of 
the  uterus,  disease  of  its  structure,  etc. 

The  symptoms  of  postpartum  hemorrhage  are  those 
of  external  bleeding  and  the  effects  of  the  loss  of  blood 
on  the  patient — pale  face  and  lips,  cold  sweat  on  the 
forehead,  rapid  running  pulse,  rapid  breathing,  yawning; 
the  patient  complains  of  being  dizzy,  faint,  “clutching  at 
the  heart”  (precordial  anxiety),  has  ringing  in  the  ears, 
and  is  sometimes  blind.  If  the  bleeding  is  not  soon  con- 
trolled, the  symptoms  aggravate,  the  woman  is  restless, 
has  cramps  in  the  muscles,  becomes  unconscious,  and 
dies.  Happily,  such  extreme  cases  are  rare,  and  with 
the  exception  of  a woman  whose  blood  is  pathologically 
altered  so  that  it  will  not  clot,  nearly  all  patients  can  be 
saved  by  the  means  we  now  have  at  our  command.  If 
the  hemorrhage  comes  on  before  the  placenta  is  out,  the 
doctor  usually  removes  the  latter;  if  the  hemorrhage 
should  come  on  after  the  placenta  is  out,  the  physician 
massages  the  uterus,  gives  ergot,  a hot  uterine  douche, 
swabs  the  uterus  with  vinegar,  packs  it  full  of  gauze,  or 
adopts  other  means  of  controlling  the  loss  of  blood. 
The  bleeding  that  occurs  after  the  physician  has  left  the 
house  is  what  concerns  the  nurse  in  actual  practice. 

A woman  in  the  first  two  hours  after  the  placenta  is 
delivered  may  lose  3 ounces  of  blood  without  there 
being  any  danger.  If  the  uterus  is  hard  and  not  too 
large,  this  is  all  right.  If  more  than  this  amount  oozes 
away;  if  there  are  clots;  and  if  the  loss  keeps  up,  the 
physician  should  be  notified.  Should  the  patient  be  sud- 
denly taken  with  a profuse  hemorrhage,  her  life  may 
depend  upon  rapid  action  of  the  nurse,  and  it  is,  therefore, 
18 


2;4 


COMPLICATIONS  DURING  LABOR 


highly  essential  that  the  latter  retains  her  presence  of 
mind. 

The  first  thing  to  do  is  to  grasp  the  uterus  and  massage 
it  vigorously.  The  uterus  may  not  be  easily  outlined, 
being  only  a big  boggy  mass  in  the  lower  abdomen.  The 
nurse  kneads  this  until  it  contracts.  The  physician 
must  be  notified,  and  if  he  is  too  far  away,  the  nearest 
one  obtainable  should  be  sent  for.  But  the  nurse  can- 
not always  wait  for  the  doctor.  She  may  administer  a 
dram  of  ergot.  If  her  massage  has  the  desired  effect,  the 
hemorrhage  ceasing  and  the  uterus  remaining  hard,  this 
is  all  that  is  necessary;  the  nurse  may  wait,  guarding  the 
uterus.  If  not,  the  flow  continuing,  she  at  once  gives  a 
hot  vaginal  douche  (120°  F.),  inserting  the  tube  about 
7 inches  and  giving  the  tube  the  upward  and  forward 
direction  of  the  parturient  canal.  If  this  does  not 
stop  the  hemorrhage,  the  nurse  should  pack  the  vagina 
as  tightly  as  possible  with  gauze,  cotton,  handker- 
chiefs, or  anything  at  hand  that  is  sterile.  After  the 
vagina  is  tightly  packed  the  nurse  places  her  fist  against 
the  packing  at  the  vulva,  and  with  the  other  hand  presses 
the  uterus  down  against  the  pelvis  (Fig.  146). 

If  her  arm  is  not  strong  enough  to  keep  up  firm  pres- 
sure, the  husband  will  have  to  help.  In  this  way  the 
hemorrhage  can  be  controlled,  or  at  least  mitigated,  until 
the  doctor  comes.  Throughout  the  nurse  must  keep  her 
presence  of  mind,  must  act  coolly  and  confidently,  and 
not  neglect  her  antiseptic  precautions. 

While  doing  these  things,  the  nurse  has  the  foot  of  the 
bed  raised  three  feet  from  the  floor  by  means  of  a table; 
she  gives  the  patient  some  strong  hot  coffee,  a hypo- 
dermic of  strychnin,  grain,  or  camphorated  oil,  if 
necessary. 

While  the  doctor  is  coming  she  has  the  husband, 
under  her  direction,  provide  towels,  hot  water,  etc.,  for 


POSTPARTUM  HEMORRHAGE  275 

eventual  operation.  Fortunately,  the  nurse  is  rarely 
called  on  to  assume  such  grave  responsibilities.  The 


writer  knows  of  only  two  instances,  and  here  massage 
with  a dose  of  ergot  accomplished  all  that  was  necessary. 

The  nurse’s  duties  while  assisting  the  physician  at  a 
case  of  postpartum  hemorrhage  are  many.  She  must 


2 y6 


COMPLICATIONS  DURING  LABOR 


see  that  the  patient  is  not  exposed  to  chilling,  that  she  is 
kept  warm  by  hot- water  bottles,  that  there  is  an  abun- 
dance of  hot  and  cold  sterile  water  for  douches,  hypo- 
dermoclysis,  and  hand  solutions.  The  physician  may 
wish  to  tampon  the  uterus,  and  for  this  will  need  a jar  of 
sterile  or  antiseptic  gauze.  (See  p.  435  for  description 


Fig.  147. — Momburg’s  belt. 


of  method  of  preparing  the  gauze  and  p.  220  for  descrip- 
tion of  operation.) 

When  a hot  douche  is  ordered,  the  nurse  should  ask 
the  degree  wanted,  and  often  the  fluid  has  a temperature 
of  1 1 50  to  1200  F Sterile  water  or  1 per  cent,  lysol 
solution  is  usually  ordered.  The  nurse  should  be  skilful 


POSTPARTUM  HEMORRHAGE  277 

in  giving  hypodermic  injections,  and  should  never  be 
found  with  a defective  syringe. 

When  the  bed  is  ordered  elevated,  a table  at  least 
30  inches  high  is  to  be  placed  under  the  foot;  a box 
on  the  table  adds  to  the  elevation  (Fig.  146).  A new 
method  of  treating  hemorrhage  is  the  Momburg  belt  (Fig. 
147) . The  aorta  is  compressed  by  a rubber  constrictor  in 
a manner  similar  to  that  used  in  amputations  of  the  ex- 
tremities. A piece  of  drainage-tube  1 yard  long  and  1 
inch  in  diameter  is  used. 

If  the  case  is  so  serious  as  to  demand  salt  solution 
transfusion,  the  nurse  prepares  for  same.  (See  p.  225 
for  details.)  Should  the  patient  faint  or  feel  like  it, 
smelling  salts  may  be  applied  to  the  nostrils  and  a stimu- 
lant hypodermic  injection  be  given  The  physician 
may  order  ether,  whisky,  camphorated  oil,  or  aromatic 
spirits  of  ammonia  to  be  given  hypodermically.  Cases 
like  this  impress  upon  the  laity  the  importance  of  skilful 
and  sufficient  attendants,  even  for  a normal  labor. 

After=care. — This  is  highly  important.  It  requires 
much  care  to  nurse  the  exsanguinated  woman  back  to 
health.  The  bed  should  be  left  raised  until  the  phys- 
ician orders  it  lowered,  which  may  be  in  from  one  to  four 
days.  When  lowering  is  ordered,  the  nurse  lets  it  down 
a foot  every  hour  until  it  is  horizontal.  Fainting  may 
result  if  it  is  lowered  suddenly. 

The  diet  is  carefully  regulated.  Liquids  in  abundance, 
short  of  causing  emesis,  are  given.  Rectal  injections  of 
saline  solution  may  be  ordered.  (See  p.  289.)  When 
food  is  acceptable,  milk,  eggs,  meat-juice,  and,  later, 
broiled  steak,  the  marrow  of  bone,  and  vegetables  rich  in 
blood  salts  (as  spinach  and  lettuce)  are  given.  The 
physician  may  order  a blood  tonic  and  a trip  to  the  sea- 
shore to  complete  the  recovery.  While  the  patient  is  in 
bed  she  must  not  raise  her  head  until  the  nurse  deems  it 


2yS  COMPLICATIONS  DURING  LAP  OR 

safe.  This  is  to  prevent  fainting.  She  may  move  in  bed 
during  the  first  few  days  only  with  great  deliberation, 
this  precaution  being  intended  to  prevent  heart  embol- 
ism. When  the  nurse  gives  such  a patient  a bath  she 
should  not  rub  the  limbs  too  vigorously,  as  clots  some- 
times form  in  the  large  veins  and  hard  friction  might 
loosen  them.  They  would  then  float  in  the  blood-stream 
to  the  heart  or  lungs,  perhaps  causing  fatal  embolism. 


CHAPTER  III 


COMPLICATIONS  OF  THE  PUERPERIUM 

Nothing  gratifies  the  physician  more  than  to  have  the 
patient  and  her  babe  make  a rapid  and  uncomplicated 
recovery  from  the  confinement.  If  a puerperal  woman 
takes  ill,  the  whole  house  is  thrown  into  gloom,  and  if 
the  child  should  sicken,  the  mother  becomes  at  once 
nervous  and  restless,  fearing  her  new  joy  is  to  be  taken 
away.  A death  during  confinement  or  after  seems 
much  worse  than  at  any  other  time,  and,  truly,  no  woman 
ought  to  lose  her  life  under  these  painful,  interesting,  and 
sympathetic  circumstances.  The  greatest  danger  to  the 
puerperal  woman  is 

PUERPERAL  INFECTION 

Puerperal  infection  may  be  defined  as  a disease,  febrile 
in  nature,  but  sometimes  non-febrile,  resulting  from  in- 
fection of  the  genital  tract  at  any  point  of  its  extent.  A 
woman  after  labor  can  have  fever  from  many  causes,  as 
sore  throat,  typhoid,  intestinal  and  urinary  disease,  but 
when  the  symptoms  point  to  an  infection  of  the  par- 
turient canal  in  any  portion  of  its  length,  she  is  suffering 
from  puerperal  infection.  In  olden  time  there  was  very 
prevalent  an  acute  febrile  disease  afflicting  puerperae, 
and  more  or  less  epidemic,  which  was  called  puerperal 
fever.  This  was  often  fatal,  and  usually  very  severe,  and 
with  definite  characteristics,  so  that  it  came  to  be  con- 
sidered a specific  fever  which  affected  only  lying-in 
women,  and  was  to  be  classed  by  itself,  like  typhus  and 

279 


280  complications  of  the  puerperium 


other  special  diseases.  Now  it  is  generally  recognized 
that  puerperal  fever  is  nothing  more  nor  less  than  septi- 
cemia, similar  to  sepsis  after  surgical  operations.  The 
term  “puerperal  fever”  is  now  occasionally  applied  to 
the  severer  forms  of  puerperal  infection,  but  it  is  best  to 
drop  the  term  entirely,  or  make  it  synonymous  with 
puerperal  infection. 

Puerperal  infection  (or  fever),  then,  is  nothing  more  nor 
less  than  infection  of  the  genital  tract,  and,  like  all  in- 
fections, may  be  mild  or  severe,  local  or  general,  and  of 
many  varieties;  like  other  infections,  too,  it  may  be  pre- 
vented. 

The  history  of  puerperal  fever  is  interesting.  It  was 
known  and  written  of  a thousand  years  before  Christ.  In 
the  Ayur  Veda  of  Susruta  it  is  mentioned,  and  the  father 
of  medicine,  Hippocrates,  who  lived  400  b.  c.,  writes  of 
it,  saying  there  was  an  epidemic  and  “the  daughter  of 
Telebulos  died  of  it  on  the  sixth  day.”  It  prevailed  all 
through  the  ages,  and  when  hospitals  were  started  it 
broke  out  with  greater  fury.  In  the  Paris  Hotel  Dieu  in 
1664  it  killed  10  per  cent,  of  the  women  confined.  In 
1823  it  carried  off  19  per  cent. — nearly  1 in  5— of  the 
women  confined  in  the  Vienna  Maternity. 

The  cause  of  the  disease  was  unknown.  It  was  as- 
cribed to  a stoppage  of  the  lochial  flow,  to  a turning  in- 
ward of  the  milk,  to  catching  cold,  to  atmospheric  con- 
ditions, etc.  In  the  early  part  of  the  last  century  Den- 
man, of  England,  taught  that  it  could  be  carried  from 
one  patient  to  another  by  the  doctor  or  midwife,  and  that 
the  doctor  could  carry  it  from  his  erysipelas  and  suppu- 
rating cases. 

The  credit  for  having  recognized  the  cause  of  puer- 
peral infection  and  forcing  the  knowledge  of  it  on  the 
medical  profession  belongs  to  Semmelweis  (Fig.  148),  of 
Budapesth,  Hungary.  Semmelweis,  then  a young  intern 


PUERPERAL  INFECTION 


28 


in  the  Obstetric  Clinic  of  the  General  Hospital  of  Vienna, 
in  1846  noticed  that  the  midwives’  clinic  adjoining  had 
a low  mortality—  about  1.5  per  cent. — while  the  clinics 
where  students  were  taught  and  he  practised  had  15  per 
cent.  This  galled  him,  as  his  was  a conscientious  nature. 
The  difference  between  the  clinics  was  so  marked  that 
the  servants  had  quarrels  over  the  conditions,  and  the 


Fig.  148. — Ignatz  Semmelweis,  the  discoverer  of  the  cause,  and  the  inventor  of 
the  means  for  the  prevention,  of  childbed  fever,  or  puerperal  infection. 


midwives  did  not  fail  to  taunt  the  medical  assistants  with 
the  facts. 

Semmelweis  worked  hard  and  long  to  find  the  solution 
of  the  trouble,  and  did  not  succeed  until  a sad  accident 
showed  it  to  him.  His  friend,  Kolletschka,  infected  his 
finger  at  a postmortem  and  died  of  sepsis.  Semmelweis 
saw  the  autopsy  of  his  friend,  and  was  struck  with  the 


282 


COMPLICATIONS  OF  THE  PUERPERIUM 


similarity  of  the  postmortem  findings  to  his  own  findings 
in  the  puerperal  fever  cases.  Eureka! 

Semmelweis  now  argued  that  the  cadaveric  poisons 
were  carried  on  the  hands  of  the  students  and  physicians 
to  the  lying-in  women.  It  was  a fact.  The  students 
would  go  directly  from  the  morgue  to  the  confinement 
room.  It  was  a wonder  that  any  women  escaped. 

Semmelweis  immediately  ordered  the  students  and 
assistants  to  clean  their  finger-nails  (a  novel  procedure  in 
those  days)  and  to  wash  their  hands  with  chlorin  water 
— the  best  deodorant  they  possessed  at  that  time — and 
the  results  were  striking.  The  mortality  in  his  clinic 
sank  below  that  of  the  midwives’  clinic.  Soon  Semmel- 
weis learned  that  there  were  other  causes  of  puerperal 
fever. 

In  the  confinement  room  were  13  beds.  A woman  in 
bed  No.  1 had  a gangrenous  cancer  of  the  cervix;  12 
other  patients  (parturient  women)  in  the  confinement 
room  were  examined  by  the  doctors  who  had  examined 
the  first.  Eleven  of  the  12  women  died  of  childbed 
fever. 

Thus  he  developed  his  theory  as  it  is  held  and  accepted 
to-day,  that  puerperal  fever  is  caused  by  the  introduction 
into  the  genitals,  from  without,  of  septic  material. 

Oliver  Wendell  Holmes,  of  Boston,  had  tried  before 
this  to  prove  to  the  medical  profession  that  puerperal 
fever  was  a “private  pestilence,”  and  that  the  doctor 
could  and  did  carry  it  about,  but  his  teaching  was  not 
fully  accepted,  nor  was  that  of  Semmelweis,  either  here 
or  abroad,  until  Pasteur,  Koch,  and  others  developed  the 
science  of  bacteriology. 

To  Semmelweis,  however,  belongs  the  undying  credit 
of  having  proved  the  cause  of  this  fearsome  scourge  and 
having  pointed  out  the  manner  of  its  prevention,  and 
his  name  must  be  mentioned  with  that  of  Jenner  and 


PUERPERAL  INFECTION 


283 


other  great  savers  of  human  life.  The  slowness  of  the 
medical  world  in  accepting  his  theory  and  his  constant 
effort  to  force  it  to  do  so  drove  him  crazy  He  died  in 
an  insane  hospital,  fatefully  enough,  just  as  did  his  friend 
Kolletschka,  from  an  infected  wound  acquired  at  an 
autopsy. 

Frequency  and  Source.— It  is  sad  to  have  to  say 
that  thousands  of  women  are  sacrificed  every  year  to 
this  dread  disease.  That  6000  women  die  from  it 
in  the  United  States  every  year  is  a very  conservative 
estimate.  In  the  maternities  a case  of  sepsis  is  rare,  and 
a fatality  from  infection  is  almost  unknown,  but  in  pri- 
vate practice  the  disease  is  still  frequently  met  with, 
although  in  a milder  form  than  in  the  olden  time.  The 
number  of  women  dating  permanent  invalidism  from  a 
mild  infection  during  childbirth  is  legion.  More  women 
die  and  are  wounded  in  confinement  every  year  than  men 
die  and  are  wounded  on  the  field  of  battle.  It  has  been 
well  said  that  the  confinement  room  is  the  woman’s 
battlefield. 

Where  does  the  infection  come  from?  From  a case 
of  puerperal  infection;  infected  abortions;  from  the 
lochia  of  puerperal  women  (not  necessarily  with  fever); 
from  a menstruating  woman;  from  any  suppurating  sur- 
face— for  example,  ulcers,  abscesses,  phlegmon,  running 
ear,  ozena;  from  erysipelas,  scarlet  fever,  and  diphtheria 
cases;  from  the  dirt  under  the  finger-nails — in  short,  any- 
thing that  is  not  absolutely  sterile  will,  if  introduced  into 
the  genital  tract,  cause  infection. 

It  is  certain  that  the  vagina  of  even  a normal,  healthy 
pregnant  woman  contains  bacteria,  and  these  are  some- 
times virulent;  and  it  is  true  that  under  certain  circum- 
stances these  germs  may  enter  the  system  and  cause  dis- 
ease. We  call  this  auto-infection.  Nature  protects  the 
woman  from  infection  by  the  following  means:  First,  the 


284  COMPLICA  TIONS  OP  THE  PUERPERIUM 


patient  has  a natural  immunity  against  infection;  she 
can  overcome  a certain  amount,  and  this  varies  much  in 
different  women  and  in  the  same  woman  at  different 
times.  The  writer  believes  that  the  woman  brought 
up  and  living  in  squalor  can  stand  infection  better  than 
the  delicately  bred  woman.  What  the  nature  of  this 
immunity  is  we  do  not  know.  We,  therefore,  do  not 
trust  to  such  uncertain  protection  in  treating  our  obstet- 
ric cases.  Second,  the  vagina  has  bactericidal  power. 
Third,  the  germs  are  not  carried  upward  in  a normal 
labor,  but  down  and  out,  the  liquor  amnii  and  the  blood 
helping  to  wash  them  out.  The  great  danger  is  in  the 
doctor  or  the  nurse  carrying  them  up  into  the  uterus. 

The  Prevention  of  Puerperal  Infection.  -Never 
was  the  saying  truer  than  here  that  an  ounce  of  preven- 
tion is  worth  a pound  of  cure.  As  yet  we  know  no  cer- 
tain cure  for  infection  that  has  once  obtained  a foothold 
in  the  genitals,  but  we  can  almost  absolutely  prevent  the 
introduction  of  alien  bacteria.  In  the  rarest  instances 
the  patient  herself  is  responsible  for  her  illness,  but  the 
rule  is  that  the  patient,  should  she  present  any  form  of 
sepsis,  has  been  infected  from  the  outside. 

The  carrier  of  this  infection  to  the  genital  tract  may  be 
the  doctor,  the  nurse,  the  patient  herself,  the  husband, 
or  some  one  else,  and  these  facts  indicate  how  extensive 
must  be  our  efforts  to  preserve  the  parturient  from 
danger. 

For  the  doctor,  there  are  two  grand  principles  for  the 
prevention  of  infection:  first,  to  reduce  to  a minimum 
the  necessary  injuries  (tears,  bruises,  etc.)  of  labor; 
second,  to  see  that  nothing  infected  comes  in  contact 
with  the  genital  tract.  The  doctor,  therefore,  will  not 
interfere  unnecessarily  in  the  conduct  of  the  labor,  will 
not  examine  too  much,  but,  in  short,  will  allow  as  natural 
a course  of  labor  as  possible. 


PUERPERAL  INFECTION 


285 


The  Asepsis  of  the  Nurse. — A nurse  will  not  go 
from  an  infected  case  to  a labor.  A full  week  should 
elapse,  during  which  time  she  should  bathe  and  shampoo 
her  hair  frequently.  She  should  take  care  of  her  person, 
have  her  teeth  sound,  and  attend  to  any  possible  catarrh. 

The  hands  require  special  care.  The  arts  of  the 
manicure  are  not  to  be  despised,  which  advice  may  well 
apply  to  physicians.  Constant  scrubbing  and  the  use 
of  strong  antiseptics  ruin  the  skin,  therefore  rubber 
gloves  should  be  used  wherever  possible.  A smooth 
skin  is  easily  cleansed;  a rough  one,  not.  Rings  are  never 
to  be  worn  while  in  attendance  on  a confinement  case. 

The  nurse  wears  a freshly  laundered  uniform  in  the 
confinement  room,  and  does  not  go  on  the  street  with  it. 
This  is  neither  asepsis  nor  good  taste. 

A needed  warning  to  the  nurse  is  never  to  relax  the 
stringency  of  her  aseptic  precautions.  It  is  so  easy  to 
grow  careless  and  desultory.  But  a day  of  reckoning 
will  surely  come,  and  if  a nurse  feels  she  is  responsible 
for  some  dear  mother’s  death  her  remorse  will  be  un- 
assuageable. 

The  nurse’s  duties  during  the  labor  are  to  provide  the 
sterile  basins,  solutions,  pledgets,  towels,  etc.,  just  the 
same  as  for  a laparotomy.  Her  hands  should  be  as 
sterile  as  possible  throughout  the  labor,  but  she  may 
not  touch  aseptic  things  or  the  patient  until  she  has 
taken  time  thoroughly  to  sterilize  her  hands.  She  must 
not  insert  her  fingers  in  the  patient’s  genitals  without 
express  orders  from  the  physician.  A long  forceps  with 
which  to  hand  things  to  the  doctor  is  very  convenient. 
When  not  in  use,  these  forceps  may  be  kept  in  a tall  jar 
(an  olive  bottle,  for  example)  of  1 per  cent,  lysol  solution. 
These  forceps  are  a necessary  part  of  the  nurse’s  outfit. 

During  the  puerperium  the  hands  must  be  sterilized 
each  time  the  genitals  are  dressed.  The  nurse  should 


286  COMPLICATIONS  OF  THE  PUERPERIUM 


arrange  everything  needed  near  the  bed,  and  then  ster- 
ilize her  hands  for  the  dressing.  Gloves  are  used  by 
many  nurses  with  much  satisfaction.  Others  use  the 
sterile  dressing  forceps.  The  vigilance  against  infection 
should  last  throughout  the  puerperium. 

The  same  care  must  be  exercised  in  the  dressing  of 
the  umbilicus  of  the  infant.  Many  children  die  every 
year  from  infection  of  the  navel,  and  this  is  preventable. 
The  eyes  of  the  infant,  too,  may  be  infected  by  the  fingers 
of  the  nurse. 

Of  great  importance  is  the  asepsis  of  the  breasts.  The 
nurse  may  carry  infection  to  them  from  the  lochia  or 
other  source,  and  cause  mastitis  and  abscess.  As  it  is 
impracticable,  though  desirable,  to  sterilize  the  hands 
each  time  the  baby  is  put  to  the  breast,  the  nurse  must 
take  care  that  the  fingers  do  not  come  in  contact  with 
the  nipple.  If  this  is  necessary,  the  hands  must  be  clean. 
These  aseptic  precautions  must  be  doubled  if  there  is  a 
crack,  fissure,  or  blister  on  the  nipple  The  use  of  ster- 
ilized cotton  applicators  for  washing  the  nipple  is  to  be 
highly  recommended.  Altogether,  the  contact  of  the 
fingers  with  the  parturient  is  to  be  systematically  avoided 
and  sterile  things  substituted,  as  gloves,  applicators,  etc. 

A woman  who  escapes  a mastitis  for  two  months  will 
almost  surely  be  able  to  finish  nursing  without  trouble. 
Thus  the  chief  duty  of  the  nurse  during  the  puerperium 
is  to  fight  germs  at  all  the  points  where  they  attack  the 
mother  and  babe,  and  success  will  attend  only  con- 
scientious and  continuous  efforts. 

Symptoms. — The  symptoms  of  puerperal  infection 
are  very  varied.  Usually  a severe  attack  is  evidenced 
by  malaise,  a chill,  fever,  rapid  pulse,  and  all  the  symp- 
toms that  accompany  a febrile  attack.  Locally  there 
are  usually  pain  around  the  uterus,  altered,  not  neces- 
sarily foul-smelling,  lochia,  sometimes  cessation  of  the 


PUERPERAL  INFECTION 


287 


same;  the  little  wounds  around  the  vulva  take  on  an 
unhealthy  aspect,  and  in  some  cases  signs  of  peritonitis 
develop,  while  in  others  abscesses  form. 

The  cases  are  of  all  degrees  of  severity,  and  their 
courses  are  irregular,  except  when  the  infection  is  severe. 
Here  a peritonitis  almost  always  carries  the  patient  off 
in  a few  days.  It  is  impossible  to  go  further  into  this 
subject  here,  because  it  is  a very  large  one. 

Every  puerperal  woman  that  has  fever  is  not  neces- 
sarily septic,  but  sepsis  is  the  first  thing  to  be  thought 
of,  and  we  shut  out  other  causes — sore  throat,  mastitis, 
constipation,  and  the  essential  fevers  like  typhoid — before 
coming  to  a positive  diagnosis  of  puerperal  infection. 
That  a woman  may  have  fever  from  the  bowels  is  pos- 
sible, but  simple  constipation  does  not  cause  it.  Some- 
times a sharp  rise  of  temperature  subsides  completely 
and  finally  when  the  bowels  were  thoroughly  evacuated. 
One  must  be  very  careful  not  to  call  a fever  in  the  puer- 
perium  intestinal  in  origin  without  careful  examination 
and  mature  deliberation. 

Treatment  of  Puerperal  Infection.  -In  this  dis- 
ease as  much  may  be  expected  from  good  nursing  as 
from  medical  and  surgical  treatment.  Every  effort  is 
made  to  develop  the  patient’s  resisting  powers,  to 
strengthen  her  so  that  she  can  throw  off  the  disease. 
For  this,  her  surroundings  should  be  the  best  obtainable; 
the  outdoor  treatment  of  such  cases  has  been  tried  with 
success;  at  all  events,  a bright,  sunny  room,  well  venti- 
lated and  free  from  noises,  should  be  selected;  household 
worries  should  be  kept  from  her,  and  the  family  should 
be  admonished  to  be  cheerful  and  not  show  the  patient 
signs  of  anxiety.  Visitors  should  not  be  allowed  until 
convalescence  is  well  established. 

The  skin  excretes  poisons,  and  the  nurse  will,  there- 
fore, see  that  this  function  is  not  interfered  with.  A 


288  COMPLICATIONS  OF  THE  PUERPERIUM 


daily  sponge-bath  with  water  containing  a little  eau  de 
Cologne  or  Florida  water  and  a soap-and-water  bath 
every  third  day  are  sufficient. 

If  the  patient  has  a chill,  the  nurse  surrounds  her  with 
hot-water  bottles,  gives  her  a hot  drink,  and  covers  her 
up  warmly.  When  a sweat  comes  on,  the  nurse  sees 
that  the  puerpera  does  not  take  cold  by  rubbing  the 
body  with  a little  warm  water  and  alcohol.  If  the 
course  of  the  disease  is  prolonged,  the  nurse  will  institute 
proper  treatment  to  prevent  bed-sores,  as  gentle  washing 
with  weak  alcohol,  followed  by  a little  oil,  the  use  of 
salves,  making  a ring  of  adhesive  plaster  with  carded 
wool  in  the  center,  the  use  of  a felt  cushion,  of  the  air- 
cushion,  frequent  change  of  position,  etc.  One  of  the 
best  means  to  prevent  bed-sores,  as  well  as  to  preserve 
the  strength  of  the  patient,  is  the  use  of  an  invalid  bed. 
The  patient  is  elevated  on  this  for  the  attentions  to  the 
genitals,  bowel  movements,  etc.,  and  also  to  relieve  the 
sacrum  from  continuous  pressure.  In  the  absence  of  an 
invalid  bed,  the  symphysiotomy  frame  (see  Fig.  107) 
does  equally  good  service. 

The  dressings  of  the  vulva  need  be  frequent,  as  the 
discharges  are  irritating,  sometimes  even  corrosive. 
Antiseptics  should  not  be  too  strong.  The  physician’s 
advice  should  be  sought  here. 

The  bowels  will  need  attention.  If  there  is  diarrhea, 
the  physician  will  usually  prescribe  something;  if  con- 
stipation, the  nurse  will  probably  be  instructed  to  give 
enemata.  The  nurse  should  call  the  physician’s  atten- 
tion to  the  state  of  the  intestinal  canal  and  the  character 
of  the  evacuations.  If  there  is  much  tympany  the 
physician  may  order  turpentine  stupes  to  the  abdomen, 
and  the  nurse  sees  that  they  do  not  blister.  He  may 
also  order  carminative  enemata  or  the  rectal  tube.  For 
abdominal  symptoms  of  peritonitis,  ice  or  hot  applica- 


PUERPERAL  INFECTION  289 

tions  may  be  applied  to  the  belly;  there  should  be  ordy 
one  layer  of  cloth  between  an  ice-bag  and  the  skin. 

Should  the  patient  become  delirious  the  nurse  must 
watch  her,  not  leaving  her  alone  a minute,  as  she  may 
jump  out  of  the  window  or  destroy  her  infant.  An  acute 
mania  may  develop  in  these  cases.  Septic  patients  are 
often  placed  in  the  Fowler  position,  that  is,  a half-sitting 
posture,  to  favor  uterine  drainage.  For  this  purpose  a 
back-rest  is  used,  or  the  head  of  the  bed  is  raised. 

Nourishment. — Liquid  diet  is  ordered  at  the  begin- 
ning, but  if  the  case  promises  to  continue  a length  of 
time,  semisolid  nourishment  may  be  ordered.  (See 
Dietary,  p.  452.)  Nourishment  should  be  pressed  on 
the  patient,  and  the  appetite  tempted  with  all  the  art 
the  nurse  possesses.  If  the  stomach  should  prove  in- 
tolerant, the  strongest  ally  in  fighting  this  disease  is  lost, 
therefore  the  nurse  should  not  err  on  the  side  of  too  much 
zeal. 

There  are  many  new  food  preparations  on  the  market, 
such  as  somatose,  peptonoids,  and  tropon,  but  the  best 
results  are  obtained  if  the  patient  can  eat  and  digest  well- 
prepared.  home  foods. 

In  the  vomiting  of  peritonitis  both  doctor  and  nurse 
stand  powerless.  Washing  the  stomach  helps  only  for 
a short  time.  In  extreme  wasting,  inunctions  of  ben- 
zoinated  lard  are  recommended,  and,  as  an  aid,  rectal 
alimentation.  Salt  solution  may  be  given  hypodermic- 
ally or  by  the  rectum. 

Rectal  infusion  of  saline  solution  by  the  drop 
method  is  much  used  in  the  treatment  of  puerperal  sep- 
sis (Fig.  149) ; 2 teaspoonfuls  of  common  salt  in  1 quart  of 
warm  water  give  the  right  proportion.  The  douche-bag 
is  hung  on  the  bed-post  with  a hot-water  bag  alongside, 
both  wrapped  in  a towel.  The  hot- water  bag  keeps  the 
saline  solution  warm.  The  douche-bag  tube  is  connected 
19 


29O  COMPLICATIONS  OF  THE  PUERPERIUM 


with  a small  catheter,  and  by  means  of  a pair  of  artery 
forceps  the  tube  is  clamped  so  as  to  allow  the  solution 


Fig.  149. — Continuous  administration  of  saline  solution  per  rectum.  The 
douche-bag  is  wrapped  with  the  hot-water  bag  in  a large  towel.  Thus  the  heat 
of  the  solution  is  maintained  during  the  prolonged  administration.  The  artery 
forceps  regulates  the  flow. 

to  drip  from  the  catheter  about  one  drop  each  second. 
This  is  called  the  “drop  method.”  The  catheter  is  then 
placed  in  the  rectum.  Sometimes  the  salt  water  is 


PUERPERAL  INFECTION 


29I 

absorbed  as  fast  as  it  flows  in;  again,  the  patient  cannot 
retain  it  long.  Usually  the  patient  has  to  be  placed  on 
a bed-pan,  which  is  very  uncomfortable  unless  a rubber 


Fig.  150. — Vacuum  bottle  used  as  irrigator.  The  cork  shown  at  the  side  carries 
two  glass  pipes,  the  rubber  tube  being  attached  to  the  shorter  one. 

utensil  is  at  hand.  Instead  of  the  douche  bag  a vacuum 
bottle  may  be  used,  arranged  as  in  Fig.  150,  or  an  elec- 
tric light  may  be  immersed  in  the  solution. 


COMPLICATIONS  OF  THE  PUERPERIUM 


29 


2 


Fig.  151. — Arrangement  for  giving  vaginal  douche.  The  dressings  and  enemata  are  prepared  for  in  the  same  manner. 


PUERPERAL  INFECTION 


293 


The  salt  water  stimulates  the  lymphatics  of  the  pelvis 
and  helps  to  wash  the  poisons  out  of  the  system. 

Medicinal  Treatment.  -Unfortunately,  we  possess  no 
medicine  that  is  a specific  for  infections.  Antistrepto- 
coccic serum,  vaccines,  Crede’s  ointment,  and  other 
remedies  may  be  exhibited  by  the  physician.  At  one 
time  alcohol  was  much  used,  and,  to  a small  extent,  still 
has  a place  in  the  treatment.  When  given,  whisky  or 
brandy  was  preferred  and  in  large  doses.  The  fever  is 
best  treated  by  cool  sponging.  Ice-packs  are  too  depress- 
ing, and  the  cold  bath  involves  too  much  disturbance  of 
the  patient.  Sometimes  a warm  pack  reduces  the  tem- 
perature better. 

Surgical  Treatment.  —The  nurse  may  be  called  upon 
to  assist  at  internal  examinations  of  the  patient,  to  pre- 
pare for  uterine  douches,  for  curettage,  even  for  major 
operations  by  the  vaginal  or  abdominal  route.  The 
methods  of  preparation  for  all  these  are  given  in  appro- 
priate chapters,  so  that  repetition  is  unnecessary.  The 
nurse  should  not  be  expected  to  give  uterine  douches, 
although  the  physician  may  instruct  her  to  do  so.  A 
uterine  douche  is  a more  serious  matter  than  was  for- 
merly thought.  Vaginal  douches  may  be  ordered  fre- 
quently given,  but  many  physicians  are  changing  their 
practice  in  this  regard  too.  The  writer  does  not  use 
them  in  sepsis.  The  arrangement  for  giving  the  vaginal 
douche  is  shown  in  Fig.  151.  When  an  abscess  forms 
around  the  uterus,  the  physician  may  open  it,  and  in 
some  cases  the  uterus  itself  is  removed. 

The  Child.  —It  is  best  for  the  patient  not  to  nurse  the 
baby  if  her  illness  is  at  all  severe — first,  because  she  has 
not  the  vitality;  second,  her  milk  is  none  too  good  for 
the  infant;  third,  the  infant  may  become  infected  by  be- 
ing so  close  to  a focus  of  infection.  As  it  is,  the  babe  runs 
great  danger  of  infection  through  the  nurse  unless  the 


294  COMPLICATIONS  OF  THE  PUERPERIUM 

latter  is  fully  alive  to  the  situation  and  takes  the  extra- 
ordinary precautions  necessary. 

The  nurse,  if  there  is  only  one,  should  use  sterile 
rubber  gloves  whenever  she  touches  the  discharges  of 
the  mother,  and  another  pair  when  she  dresses  the  navel 
of  the  child.  It  is  better  to  have  a special  nurse  for  the 
infant.  If  the  child  does  not  nurse,  the  breasts  should 
not  be  pumped  in  the  hope  of  preserving  the  milk. 
Pumping  will  not  preserve  the  supply  if  nursing  is  long 
interrupted,  and  it  may  lead  to  an  abscess  in  the  breast. 
The  milk  will  return  itself  if  the  child  is  put  again  to  the 
breast  after  not  too  long  an  interval.  The  author  has 
seen  the  milk  return  after  three  weeks.  The  child  may 
be  with  its  mother  very  little,  and  precautionary  meas- 
ures should  be  constant  in  preventing  infection  from 
reaching  its  navel,  eyes,  and  throat. 

The  Nurse.  For  difficult  cases  of  puerperal  infection 
two  nurses  are  really  needed,  and  there  is  plenty  of  work 
for  both.  It  is  better  if  one  nurse  takes  the  mother  and 
the  other  the  child.  The  nurse  should  insist  on  getting 
at  least  six  consecutive  hours  of  sleep  daily  and  several 
hours  of  recreation  in  the  sunny  part  of  the  day,  which 
should  be  her  opportunity  to  go  out  and  revivify  her 
blood  with  fresh  air  and  sunshine.  The  patient,  too,  will 
be  better  for  it. 

The  nurse  must  be  careful  not  to  infect  her  own  hands. 
Fatalities  are  known.  She  must,  therefore,  care  for  all 
cracks  and  hang-nails.  It  is  wise  to  use  rubber  gloves 
for  the  vulvar  dressings,  for  this  reason  as  well  as  for 
those  previously  mentioned.  If  the  slightest  irritation  is 
observed  on  the  hands,  the  physician’s  advice  should  be 
sought.  Infection  of  the  nurse’s  eyes  has  occurred, 
therefore  the  nurse  should,  as  should  all  hospital  or 
sick-bed  attendants,  learn  to  avoid  rubbing  the  eyes 
and  face  while  on  duty. 


PUERPERAL  INFECTION 


295 

History  Sheet.  —The  temperature  in  septic  cases  is 
very  irregular,  and  the  physician  will  wish  it  taken  every 


GRAPHIC  CLINICAL  CHART. 


the  temperature;  the  dotted  line,  the  pulse. 


four  hours,  also  the  pulse  and  respiration.  A full  history 
sheet  should  be  kept  and  all  unusual  occurrences  noted. 
Graphic  history  sheets  aid  the  physician  in  acquainting 


296  COMPLICATIONS  OF  THE  PUERPERIUM 


himself  with  the  case,  therefore  the  nurse  should  learn 
how  to  make  them  (Fig.  152). 

Disinfection.  —All  pads  and  cloths  soiled  by  the  dis- 
charges from  the  patient  should  be  wrapped  in  newspa- 
pers as  soon  as  removed  and  burned.  Sheets,  towels,  etc., 
should  be  thrown  into  a tub  of  3 per  cent,  carbolic  solu- 
tion and  allowed  to  soak  several  hours  before  they  are 
sent  to  the  laundry.  In  the  laundry  the  time  of  boiling 
the  clothes  should  be  at  least  forty  minutes,  and  the 
boiler  must  be  tightly  closed.  The  blankets  used 
about  the  patient  should  be  washed  like  other  bed-linen. 
An  effort  is  to  be  made  to  limit  the  infection  to  the 
room  occupied  by  the  patient.  The  nurse,  therefore, 
keeps  her  utensils  together,  protects  tables  and  other 
furniture  from  being  soiled  by  the  discharges,  and  keeps 
the  bath-room  free  from  infection. 

The  physician  should  be  provided  with  a sterile  gown 
for  his  visit  or  examination,  and  with  sterile  soap  and 
towel  for  his  hands  on  leaving. 

The  discharges  from  the  vulva,  from  abscesses,  or 
from  wounds  should  be  caught  in  antiseptic  dressings, 
and  these  surfaces  kept  clean  by  frequent  dressings. 
The  room  is  kept  free  from  odor  by  full  ventilation  and 
sunlight.  A sun-bath  will  do  the  patient  good. 

After  the  case  is  terminated  the  patient  is  given  a new 
bed;  the  mattress  she  occupied  is  burned,  and  the  bed 
taken  down  into  the  yard  and  scrubbed  and  carbolized. 
Basins  are  boiled  and  furniture  scrubbed  with  3 per 
cent,  carbolic  solution.  The  room  is  thoroughly  fumi- 
gated with  formalin  (see  p.  440),  and,  in  general,  the  case 
treated  as  one  of  the  contagious  diseases,  although  it  is 
not  contagious  in  the  accepted  sense  of  the  term. 

On  leaving  the  case  the  nurse  sends  all  the  clothes  she 
wore  while  on  it  to  the  laundry,  and  after  a full  bath  and 
hair  shampoo  dons  aseptic  apparel.  For  the  next  four 


PUERPERAL  THROMBOSIS 


29  7 


days  a daily  full  bath  and  hair  shampoo,  using  a great 
deal  of  soap,  are  recommended.  The  nurse  may  ask 
why  she  is  required  to  undergo  such  thorough  cleansing, 
when  the  physician  goes  about  among  such  heterogeneous 
cases  without  as  many  precautions.  Let  her  remember 
that  the  physician  stays  with  each  patient  but  a few 
minutes,  and  has  a change  of  air  between  each  two 
calls,  while  she  is  in  the  infected  atmosphere  nearly 
seventeen  hours  out  of  the  twenty-four.  Then,  too, 
if  she  goes  to  a new  patient  susceptible  to  infection, 
her  more  intimate  association  with  the  case  invites 
sepsis,  even  if  she  carries  but  very  little  with  her. 

PUERPERAL  THROMBOSIS 

The  blood  in  the  veins  of  the  legs  may  stagnate  and 
clot;  this  is  called  thrombosis.  The  return  circulation 
being  thus  shut  off,  the  part  becomes  edematous.  Usu- 
ally there  is  little  fever  with  this — a mechanical  throm- 
bosis due  to  poor  circulation  and  to  the  fact  that  the  veins 
are  enlarged  and  tortuous.  The  element  of  danger  in 
these  thromboses  is  that  a bit  of  clot  may  break  off  and, 
carried  by  the  blood-stream,  reach  heart  and  lungs.  This 
is  called  embolism,  and  is  often  fatal.  The  nurse  will 
seek  to  prevent  embolism  by  keeping  the  affected  limb 
very  quiet  for  several  days,  and  by  not  rubbing  or  mas- 
saging it.  Care  should  be  exerted  when  the  patient 
moves  in  bed  and  when  the  limb  is  bathed. 

If  an  infection  proceeds  from  the  sides  of  the  uterus 
and  attacks  the  cellular  tissue  and  the  veins  about  the 
pelvis,  a condition  called  phlegmasia  alba  dolens 
results.  By  the  laity  this  is  called  “milk-leg,”  and  refers 
to  the  ancient  notion  that  it  is  due  to  “driving  in  of  the 
milk.”  It  really  is  an  infection  which  travels  along  the 
veins  and  the  cellular  tissue  of  the  pelvis.  One  or  both 
legs  may  be  affected.  The  limb  is  swollen  and  painful, 


298  COMPLICATIONS  OF  THE  PUERPERIUM 

and  the  skin  is  tense  and  white,  almost  translucent.  It 
is  very  tender  to  the  touch.  Convalescence  takes  weeks 
or  months,  and  often  the  leg  remains  swollen  or  swells 
when  the  patient  is  long  on  her  feet. 

The  nurse  will  be  instructed  to  keep  the  patient  very 
quiet,  to  elevate  the  limb  a little  (Fig.  153),  to  apply  a 
warm,  moist  dressing,  a bandage,  or  special  medicines. 


Fig.  153. — The  box  used  for  elevating  the  leg  in  phlegmasia  alba  dolens.  It  is 
smoothly  padded  with  cotton  covered  with  gauze.  An  air  cushion  is  placed 
under  the  tendo  Achilles.  If  the  foot  tends  to  fall  outward  it  may  be  supported 
by  a light  adhesive  strap  to  the  foot-board.  In  summer  this  may  be  made  of 
wire  netting. 


The  foot  must  not  be  allowed  to  support  the  bed  clothes, 
as  “drop  foot”  will  result.  A cradle  is  used  to  prevent 
this.  Bed-sores  will  result  from  poor  nursing  of  the 
case.  Later  on,  when  the  fever  is  gone  and  signs  of 
inflammation  are  absent,  the  doctor  may  prescribe  gentle 
massage.  Sometimes  these  cases  are  only  part  of  a 
general  blood-poisoning  or  pyemia,  and  then  they  are 
really  serious,  usually  fatal. 


TYMPANY 


299 


AFTER-PAINS 

Primiparae,  unless  the  uterus  contains  a clot,  are 
not  troubled  with  painful  uterine  contractions  after 
the  child  is  born — “ after-pains  ” as  they  are  called. 
Multipart  are  annoyed  by  them,  and  they  increase  in 
severity  with  succeeding  puerperiums.  They  are  due  to 
lack  of  tonicity  in  the  uterine  muscle,  or  to  the  presence 
of  a clot  or  a bit  of  placenta  in  the  uterine  cavity,  in 
which  case  they  are  especially  beneficial,  as  they  expel 
the  foreign  body.  In  all  cases  they  are  of  good  omen, 
though  the  patient  may  suffer  considerable  distress.  If 
the  nurse  tells  the  patient  this  fact,  it  may  help  her  to 
bear  with  them  until  they  disappear,  which  almost  al- 
ways occurs  within  forty-eight  hours.  During  the  nurs- 
ing of  the  infant  the  after-pains  aggravate,  due  to  the 
nervous  stimulation  of  the  uterus  through  the  breasts — 
a fact  we  make  use  of  in  practice  to  get  the  uterus  to 
contract.  In  some  women  the  after-pains  are  of  special 
severity,  and  the  physician  should  be  informed  of  it,  so 
that  he  may  prescribe  an  anodyne.  Household  remedies 
are  warm  fomentations  over  the  uterus;  a salt  solution 
enema;  compression  of  the  abdomen;  a warm  drink, 
soda-mint  tablets,  and  suggestion,  the  nurse  trying  to 
divert  the  patient’s  attention.  When  a clot  or  other 
foreign  material  is  in  the  uterus,  the  physician  may  wish 
to  remove  it.  Preparations  are  made  as  for  the  douche, 
p.  224. 

TYMPANY 

Occasionally  after  delivery  the  intestines  fill  up  with 
gas  and  the  abdomen  becomes  as  large  as,  and  some- 
times larger  than,  it  was  before  the  birth  of  the  child. 
The  condition  rarely  may  become  dangerous  or  even 
fatal.  It  seems  to  be  a paresis  of  the  intestinal  walls 
or  stomach  similar  to  that  sometimes  occurring  after 


300  COMPLICATIONS  OF  THE  PUERPERIUM 

abdominal  section.  The  physician’s  attention  should 
be  called  to  it  early,  and  he  will  prescribe  some  carmina- 
tive by  mouth  or  by  rectal  injection.  Asafetida  has 
proved  valuable  in  these  cases.  Turpentine  stupes  and 
the  high  rectal  tube  are  also  used.  An  enema  of  milk 
and  molasses,  of  each  i pint,  is  very  effective.  Chamo- 
mile tea  makes  a pleasant  enema  The  abdominal 
binder  should  be  removed.  Abdominal  massage  is 
practised  only  on  the  physician’s  order.  If  the  tympany 
is  due  to  a peritonitis,  the  outlook  is  gloomy  Nearly 
all  cases  not  due  to  inflammation  rapidly  subside  under 
treatment. 

CONSTIPATION 

Difficulty  may  be  experienced  in  getting  the  bowels 
to  move  during  the  puerperium.  In  one  case  the  author 
found  a tumor  almost  as  large  as  the  uterus  at  term 
filling  up  the  lower  abdomen,  composed  of  feces.  If 
cathartics  and  ordinary  flushings  prove  insufficient,  high 
colonic  irrigation  with  inspissated  ox-gall  and  glycerin 
may  be  ordered,  or  it  may  be  necessary,  if  the  fecal 
impaction  is  lower,  to  remove  the  mass  with  the  fingers 
and  suitable  scoop-like  instruments.  An  ox-gall  enema 
is  prepared  as  follows:  i dram  of  inspissated  ox-gall- 
is  mixed  with  2 ounces  of  glycerin  into  a smooth  paste; 
with  constant  stirring  water  is  poured  into  it  until 
the  amount  is  1 quart.  The  mixture  is  injected  slowly 
into  the  bowel  and  retained  several  hours  if  possible. 
For  removing  hardened  feces  from  the  rectum  the  patient 
is  brought  to  the  edge  of  the  bed,  warmly  covered,  be- 
cause the  operation  requires  some  time,  and  the  nurse, 
with  rubber  gloves  on,  under  an  intermittent  stream  of 
salt  solution,  loosens  and  breaks  up  the  masses.  After 
the  rectum  is  emptied,  a few  ounces  of  sterile  olive  oil 
or  vaselin  (liquefied  by  heat)  are  injected  to  allay  the 
irritation. 


VESICOVAGINAL  VISTULA 


301 


VESICOVAGINAL  FISTULA 

In  cases  of  excessively  prolonged  labor  or  of  instru- 
mental delivery,  it  occasionally  happens  that  the  wall 
between  the  bladder  and  vagina  is  torn  or  sloughs  out. 
The  resulting  communication  between  the  two  cavities 
is  called  a vesicovaginal  fistula.  If  such  a communication 


Recto- 

vaginal 


Vesicocervical. 

Ureterovaginal. 


— Vesicovaginal. 


Recto- 

perineal. 


Urethrovaginal. 


Vaginoperineal. 


Fig.  154. — Sites  of  fistulas. 

is  made  with  the  rectum  it  is  called  a rectovaginal  fistula 
(Fig.  154) . In  the  former  case  the  urine  will  escape  from 
the  vagina  continually;  in  the  latter,  the  feces  and  gas 
will  continually  soil  the  vagina.  The  nurse  will  have 
extra  work  keeping  the  parts  clean  until  they  are  suffi- 
ciently recovered  to  permit  a plastic  operation. 

After  vesicovaginal  fistula  operations  usually  a per- 


302  COMPLICATIONS  OF  THE  PUERPERIUM 


manent  catheter  is  inserted  and  continuous  drainage  of 
the  bladder  is  maintained.  The  success  of  the  operation 
depends  largely  upon  the  nurse,  because  if  she  allows 
the  catheter  to  be  plugged  with  urinary  salts  or  to  be 
kinked,  the  bladder  will  become  overdistended,  and, 


Fig.  155. — Permanent  catheter  in  place,  draining  into  bottle  hung  at  the 
side  of  the  bed.  The  rubber  tube  must  be  rigid  enough  to  resist  compression 
by  the  thigh. 


since  the  urethra  is  blocked,  the  urine  will  find  exit 
through  the  stitches,  thus  spoiling  the  operator’s  best 
work. 

A No.  16,  French  scale,  soft-rubber  catheter  is  placed 
in  the  bladder  and  fastened  to  the  thigh  with  adhesive 


CYSTITIS 


303 


plaster  (Fig.  155).  A large  glass  connector  unites  it 
with  a stout  rubber  tube  (lumen  \ inch),  leading  under 
the  thigh  into  the  mouth  of  a large  bottle  hanging  at  the 
side  of  the  bed.  The  nurse  observes  the  urine  dripping 
from  the  free  end  of  the  tube,  and  she  must  at  once  in- 
vestigate any  stoppage  of  the  flow.  The  dripping  must 
be  uninterrupted.  Night  and  morning  the  catheter  is 
removed  and  a new  one  inserted,  which  must  also  be  done 
if  the  urine  ceases  to  flow.  Medicines  are  usually  given 
to  prevent  excessive  deposition  of  salts  in  the  catheter, 
which  is  the  greatest  menace  to  success. 

CYSTITIS 

Inflammation  of  the  bladder  is  an  occasional  compli- 
cation of  the  puerperium.  It  is  usually  due  to  infecting 
catheterizations,  but  in  some  cases  injury  to  the  bladder 
during  labor  predisposes  to  the  infection.  The  nurse 
can  read  a warning  here — to  be  always  aseptic  in  her 
catheterization. 

The  symptoms  of  cystitis  are  painful  and  frequent 
urination,  vesical  tenesmus,  pain  over  the  bladder,  ten- 
derness on  pressure,  pus  and  blood  in  the  urine;  later, 
alkaline  fermentation  in  the  bladder. 

The  treatment  is  both  internal  and  local.  The  patient 
will  be  given  some  urinary  antiseptic,  like  urotropin,  and 
the  physician  will  perhaps  order  the  bladder  washed 
out  with  saline  solution  or  some  weak  antiseptic.  Wash- 
ing the  bladder  is  simple,  the  preparation  being  the 
same  as  for  catheterization.  After  the  urine  is  drawn 
off,  the  tube  of  the  douche-bag  is  attached  to  the  cath- 
eter and  the  bladder  allowed  to  fill.  The  bag  is  held  18 
inches  above  the  pubes.  The  water  is  then  allowed  to 
escape,  and  this  lavage  is  repeated  several  times  at  each 
sitting. 

If  the  physician  wishes  to  cystoscope  the  patient,  that 


304  COMPLICATIONS  OF  THE  PUERPERIUM 

is,  look  into  the  bladder,  the  nurse  will  prepare  for  this 
in  the  same  manner  as  if  she  were  going  to  wash  out  the 
organ.  In  addition  she  should  provide  a tall  jar  for 
solution  in  which  to  place  the  cystoscope,  a sterile  syringe 
holding  2 ounces,  and  i pint  of  sterile  water  as  clear  as 
crystal.  This  water  the  physician  uses  to  distend  the 
bladder  while  he  is  looking  into  it  with  the  cystoscope. 
Cystoscopes  (excepting  the  simple  tubular  ones)  must  not 
be  boiled,  and  are  to  be  delicately  handled. 

HEADACHE 

A woman  should  not  complain  of  headache  during 
the  puerperium.  If  a headache  comes  on  after  labor,  the 
nurse  should  watch  for  other  symptoms  of  eclampsia. 
If  a woman  has  lost  much  blood  at  the  labor  she  may 
suffer  from  an  anemic  headache.  There  is  a headache 
from  exhaustion,  from  too  much  excitement,  as  too 
many  or  irritating  visitors,  from  hunger,  from  too  much 
ergot,  and  from  insomnia.  Sometimes  the  eyes  are  at 
fault,  and  the  patient  may  have  to  wear  eye-glasses  in 
bed,  and  if  a woman  with  weak  eye  muscles  looks  down 
at  her  baby  all  the  time  it  is  nursing  she  may  acquire  a 
headache  from  eye-strain.  Constipation  is  another  cause 
of  headache,  and  neurasthenia  also.  The  physician  will 
inquire  into  the  cause  and  seek  the  remedy,  but  the 
nurse  may  do  much  both  in  prevention  and  cure  by 
exercising  her  art — nursing. 

PUERPERAL  INSANITY 

This  sad  accident  is  not  very  infrequent.  It  occurs 
most  often  in  women  with  an  hereditary  taint  of  insanity 
in  the  family,  in  cases  of  toxemia  during  pregnancy,  after 
eclampsia,  and  after  sepsis  postpartum.  Melancholia 
and  mania  are  both  found,  and  one  may  lead  to  the  other. 
In  both  forms  suicidal  tendencies  are  marked,  and  the 


PUERPERAL  INSANITY 


305 


mother  may  try  to  destroy  the  child.  After  recovery 
she  may  repudiate  her  own  infant,  or  only  slowly  learn 
to  love  it. 

The  symptoms  of  beginning  puerperal  insanity  are 
sleeplessness,  anorexia,  delusions  of  sight,  hearing,  smell, 
loss  of  love  for  the  infant,  even  hating  it.  The  patient 
may  become  acutely  maniacal,  with  extreme  and  exhaust- 
ing jactitation,  and  try  to  jump  out  of  the  window;  or  she 
may  lie  apathetic  and  melancholy,  but  may  suddenly 
make  an  attempt  to  kill  herself  or  the  baby. 

Treatment. — There  are  three  important  parts  of  the 
nursing  care  of  such  cases:  First,  prevent  the  patient 
from  committing  suicide  and  from  killing  the  baby; 
second,  procure  sleep;  third,  keep  up  the  nutrition. 

To  accomplish  the  first — prevention  of  suicide — the 
patient  should  be  isolated  in  a room  whose  windows  are 
barred.  If  they  are  completely  covered  with  double  wire 
fly-netting  nailed  down  it  is  sufficient,  and  does  not  give 
the  patient  the  idea  of  a prison.  All  pictures  and  extra 
furniture  should  be  removed,  and  everything  that  has  a 
polish  which  may  give  reflections  and  which  the  patient 
may  misconstrue;  also  everything  that  is  sharp  or  cut- 
ting, as  glass,  table-knives,  or  forks.  Nothing  movable 
save  the  table,  divan,  and  chairs  should  be  at  hand. 

The  patient  must  not  be  left  alone  an  instant.  Two 
nurses  are  absolutely  necessary.  When  the  child  is  with 
the  mother,  the  nurse  must  watch  her  very  sharply,  as 
she  may  strangle  the  little  one  before  it  can  be  drawn 
away  from  danger. 

The  general  rules  for  nursing  the  insane  are  applicable 
here,  and  it  is  desirable  that  a nurse  having  such  special 
training  be  employed.  For  the  exhausting  jactitation, 
gentle  restraint  may  be  absolutely  necessary,  but  one 
should  remember  that  restraint  is  also  exhausting  to  the 
patient. 

20 


30 6 COMPLICATIONS  OF  THE  PUERPERIUM 


Procuring  Sleep. — The  physician  will  prescribe  som- 
nifacient drugs,  of  which  hyoscin,  scopolamin,  morphin, 
opium,  and  chloralamid  are  usually  selected;  but  the 
nurse  may  do  much  to  procure  rest  for  the  patient.  Let 
her  give  the  enema  and  the  bath  in  the  evening,  or  an 
alcohol  rub,  with  general  massage,  followed  by  a cup  of 
hot  malted  milk  or  an  eggnog.  Absolute  quiet  must 
reign  throughout  the  house,  and  no  visitors  be  allowed. 
The  patient  must  sleep. 

N ourishment. — This  is  of  great  importance  and  diffi- 
cult, because  the  appetite  is  gone  and  the  patient  may  try 
to  die  by  starving  herself.  She  may  imagine  herself  too 
wicked  for  the  food  given  her,  or  have  other  delusions, 
and  the  nurse  may  make  use  of  her  delusions  to  insinuate 
food.  All  the  art  of  cookery  and  the  arts  of  the  nurse 
are  to  be  used  to  provide  sufficient  nourishment,  and  the 
nurse  should  keep  an  accurate  record  of  the  daily  amounts 
ingested,  so  as  to  be  able  at  all  times  to  show  the  phys- 
ician that  the  puerpera  is  not  suffering.  Should  the 
patient  refuse  nourishment,  she  will  have  to  be  fed  with 
a stomach-tube. 

Saline  solution  is  sometimes  administered  hypodermic- 
ally. It  may  make  the  patient  hungry.  If  the  mother 
has  milk,  she  may  nurse  the  infant.  Let  the  nurse  watch 
them  carefully;  usually  the  milk  secretion  diminishes, 
or  the  infant  does  not  thrive,  and  it  is  best  to  wean  it. 

These  cases  require  from  two  to  eight  months  for  re- 
covery, although  occasionally  this  may  never  be  com- 
plete. An  important  question  is  the  removal  of  the 
patient  to  a sanatorium.  In  the  writer’s  opinion,  this  is 
usually  by  far  the  best  course.  If  the  patient  can  have 
skilled  nurses  and  all  the  care  she  could  get  in  the  sana- 
torium at  her  own  home,  with  complete  isolation,  she  may 
be  as  well  cared  for  at  home. 


CHAPTER  IV 


COMPLICATIONS  OF  THE  PUERPERIUM- 
(Contmued) 

DISEASES  OF  THE  BREASTS 

The  most  common  disorder  affecting  the  breasts  is 
simple  engorgement.  The  general  notion  is  that  the 
breasts  are  overfilled  with  milk.  This  is  true  only  in 
part.  While  a small  amount  of  milk  forms  spontane- 
ously in  the  breasts,  the  symptoms  are  due  to  lymphatic 
and  venous  engorgement.  One  can  see  this  in  some 
cases,  even  the  skin  being  edematous.  The  engorge- 
ment occurs  on  the  second,  third,  or  fourth  day,  when  the 
“milk  comes  in,”  and  it  may  occur  at  the  time  of  sud- 
denly weaning  the  child,  when  the  usual  relief  of  engorge- 
ment produced  by  nursing  is  absent. 

Symptoms. — The  breasts  are  very  heavy,  painful,  and 
hot;  they  feel  warm,  but  there  is  no  rise  of  body  tem- 
perature. There  is  no  such  thing  as  “milk-fever” — a 
fever  the  ancients  ascribed  to  the  engorgement  of  the 
breasts  on  the  third  or  the  fourth  day.  Fever  at  such 
times  is  usually  due  to  infection.  Examination  of  the 
breasts  shows  them  to  be  much  enlarged,  tender,  some- 
times edematous,  and  of  a bluish,  mottled  appearance. 
The  nipple  is  flattened  so  that  the  child  cannot  grasp  it, 
and  the  secretion  of  milk  may  be  suspended — the  breasts 
are  choked  up  with  swelling.  The  part  of  the  gland 
running  up  into  the  axilla  enlarges  too,  and  the  patient 
cannot  bring  her  arm  to  the  side. 


307 


308  complications  of  the  puerperium 


If  left  alone,  the  engorgement  gradually  disappears, 
the  gland  becomes  soft,  and  the  milk  flows  readily  when 
the  child  nurses.  If  irritated  by  too  much  or  too  rough 
massage,  by  breast-pumps,  and  too  frequent  nursing,  the 
engorgement  is  slower  in  going  down,  but  it  will  gradu- 
ally disappear. 

Treatment.  The  practises  of  physicians  vary.  Some 
apply  heat;  others,  cold.  Usually  orders  are  given 
to  bind  the  breasts  tightly  (Fig.  156).  A saline  cathartic 
is  often  given  to  draw  the  blood  away  from  the  breasts. 


Fig.  156. — The  breast-binder  applied. 


Massage  is  practised  only  on  the  physician’s  order,  and 
the  same  is  advised  in  regard  to  the  breast-pump. 
Neither  massage  nor  the  breast-pump  is  to  be  employed 
when  there  are  signs  of  inflammation  in  the  breasts. 

The  practice  of  the  author  is  as  follows:  If  the  en- 
gorgement is  severe  and  causes  much  pain,  a saline 
laxative  is  ordered,  and  liquids  by  mouth  are  restricted. 
The  infant  is  allowed  to  nurse  only  every  four  hours. 
The  breasts  are  tightly  bandaged  and  an  ice-bag  is 
applied  to  each  of  them.  These  measures  will  almost 


DISEASES  OF  THE  BREASTS 


309 


always  prove  adequate.  If  they  do  not,  the  nurse  gently 
massages  the  breast  for  five  minutes  and  then  reapplies 
the  binder.  If  this  brings  no  relief,  which  is  unusual,  a 
hot  boric  dressing  is  applied.  Aseptic  gauze  is  wrung 
out  of  hot  boric  acid  solution,  both  breasts  snugly  padded 
with  it,  and  over  all  a layer  of  oiled  silk  and  a bandage 
are  placed.  This  is  sometimes  more  grateful  to  the 
patient  than  the  ice.  If  compression  is  wished  in  addi- 


Fig.  157. — Massage  of  breast:  Even  compression  of  entire  breast.  First 

motion. 


tion,  a round  oatmeal  bowl  may  be  inverted  over  each 
breast  and  bandaged  on. 

Massage  is  carried  out  as  follows:  The  nurse  sterilizes 
her  hands  and  anoints  the  breasts  with  sterile  albolene 
or  oil.  The  first  motion  (Fig.  157)  is  one  of  even  com- 
pression of  the  whole  breast.  Both  hands  are  spread 
out  as  evenly  and  smoothly  as  possible  over  the  breast, 
and  firm  compression  exerted  against  the  chest.  The 


310  COMPLICATIONS  OF  THE  PUERPERIUM 


Fig.  158. — Massage  of  breast:  Pressing  the  lymph  in  the  direction  of  the 

peripheral  lymph- vessels.  Second  motion. 


Fig.  159. — Diagram  of  the  breast  strokings  in  the  second  motion.  The  shaded 
portion  of  the  arrows  shows  the  increase  in  pressure  of  the  stroke. 


DISEASES  OF  THE  BREASTS 


311 

blood  and  lymph  are  thus  pressed  out  and  away  from 
the  gland.  On  removing  the  fingers  the  nurse  may  see 
depressions  in  the  surface.  This  pressure  is  not  painful, — 
just  the  contrary.  After  this  even  pressure  has  been 
practised  a few  minutes  and  all  the  gland  covered,  gentle 
circular  strokings  are  made  from  the  nipple  toward  the 
periphery  (Fig.  158).  The  four  fingers  make  circles 
around  the  nipples,  pressing  harder  as  they  go  away  from 


Fig.  160. — Massage  of  breast:  Wiping  the  milk  toward  the  nipple.  Third 

motion. 


the  nipple  (Fig.  159).  The  breast  is  steadied  by  the 
other  hand.  The  idea  is  to  press  the  lymph  out  of  the 
breast. 

After  circling  the  breast  twice,  the  third  motion  is  in- 
stituted (Fig.  160).  One  hand  steadies  the  breast,  while 
four  fingers  of  the  other  hand  wipe  the  milk  toward  the 
nipple.  Any  milk  formed  is  thus  squeezed  out  of  the 
nipple.  This  is  the  least  important  of  the  three  motions. 


312 


COMPLICATIONS  OF  THE  PUERPERIUM 


The  last  maneuver  is  a repetition  of  the  first,  and 
nearly  always  the  patient  will  feel  much  relieved  by  the 
procedure,  even  though  no  milk  has  been  expressed. 
The  breasts  are  now  bandaged  smoothly  and  tightly. 

Abnormalities  of  the  Nipples.  -The  normal 
nipple  varies  much  in  different  women.  Fig.  161  gives 
silhouettes  of  many  forms.  If  the  nipple  is  flat,  or  even 
depressed,  the  child  may  be  unable  to  get  hold  of  it. 


Normal  nipple. 


Polypoid  nipple. 


Flat  nipple. 


Mulberry  nipple. 


Inverted  nipple. 


Bifid  or  split  nipple. 


Fig.  1 6 1. — Diagram  of  variously  formed  nipples. 


Engorgement  of  the  breast  is  common,  and  if  fruitless 
efforts  at  nursing  are  persisted  in,  cracks  occur  and 
abscess  may  be  the  final  result.  If  the  child  cannot 
quickly  develop  a nipple  sufficient  for  sucking,  and  if  the 
milk  does  not  flow  readily  with  the  use  of  a nipple-shield 
it  is  best  to  discontinue  nursing.  During  pregnancy 
attempts  should  be  made  to  develop  undersized  and  de- 
pressed nipples.  (See  p.  89.) 


DISEASES  OF  THE  BREASTS 


313 


If  the  nipple  is  congenitally  fissured,  as  the  mulberry 
nipple;  bifid,  as  the  double  nipple,  or  pedunculated,  the 
tendency  to  crack  is  marked,  and  trouble  with  nursing  is 
inevitable. 

Cracks,  Fissures,  and  Blisters  of  the  Nipple. — 

These  are  very  important,  because  they  sometimes  ren- 
der nursing  difficult  or  impossible,  to  the  detriment  of  the 
infant,  and  they  may  also  lead  to  mastitis,  with  abscess. 
The  integrity  of  the  nipple  must,  therefore,  be  preserved. 
The  nurse  should  frequently  inspect  the  nipples,  to  de- 
tect a crack  or  blister  in  its  incipiency,  especially  if  the 
patient  complains  of  tenderness  when  the  babe  grasps 
the  nipple.  If  she  cannot  find  a crack  with  the  unas- 
sisted eye,  a magnifying-glass  in  good  light  will  usually 
show  one.  Sometimes  there  is  an  unexplained  sensitive- 
ness of  the  nipple.  This  occurs  in  neurotic  women,  and 
may  be  so  acute  as  to  forbid  nursing,  even  though  there 
is  a good  milk-supply.  Sometimes  the  infant  bites  the 
nipple  unnecessarily.  It  is  a habit,  and  should  be  cured 
by  gently  patting  him  on  the  back  until  he  learns  better. 
Sometimes  the  baby  will  not  let  go  of  the  nipple,  pre- 
ferring to  keep  it  in  the  mouth,  even  when  not  nursing.* 
This  must  not  be  allowed.  To  remove  the  nipple  from 
the  infant’s  mouth  without  hurting  the  nipple,  insert  the 
little  finger  into  the  mouth  at  the  angle  of  the  lips  and 
let  the  air  in. 

Cracks  are  longitudinal  or  circular;  the  latter  are  the 
worst.  A crack  may  deepen  into  a fissure,  and  a fissure, 
if  transverse,  may  partly  amputate  the  nipple.  If  longi- 
tudinal, it  may  split  the  nipple.  A blister  often  precedes 
a crack,  and  a little  superficial  ulcer  may  result  from  a 
blister.  Blondes  are  more  liable  to  these  affections 
than  brunets,  and  red-haired  women  seem  particularly 
predisposed,  perhaps  because  their  skin  is  so  thin  and 
delicate.  The  precautions  to  be  taken  during  preg- 


3 14  COMPLICATIONS  OF  THE  PUERPERIUM 


nancy  are  given  on  page  89,  under  The  Hygiene  of 
Pregnancy. 

As  soon  as  a crack  is  discovered,  it  should  be  reported 
to  the  physician  and  treatment  should  be  instituted.  A 
great  many  methods  are  employed.  The  author  uses 
the  following,  but  the  nurse  will  do  well  to  get  exact  in- 
structions from  the  attending  physician:  First,  the  in- 
tervals of  nursing  are  lengthened  to  four  hours  and  the 
breasts  used  alternately;  second,  Wansbrough’s  leaden 
nipple-shields  (Fig.  162)  are  applied.  These  are  little 
shields  made  of  thin  lead  having  the  shape  of  a sugar-loaf 
hat.  They  are  scoured  with  Sapolio,  boiled,  and  then  ap- 
plied to  the  nipples,  being  supported  by  a bandage.  The 


Fig.  162. — Wansbrough’s  leaden  nipple-shield. 


theory  is  that  the  lactic  acid  in  the  milk  acts  on  the  lead, 
and  the  nipple  is  bathed  continuously  in  a sort  of  lead- 
water  application.  This  explanation  has  been  ques- 
tioned, but  the  fact  remains  that  the  little  appliance  is 
very  successful  in  curing  cracked  and  ulcerated  nipples. 
To  hasten  the  cure,  or  if  the  leaden  shields  are  not  used, 
the  crack  or  blister  is  brushed  with  a 2 per  cent,  solution 
of  nitrate  of  silver.  If  there  is  a deep  fissure  or  ulcer,  it  is 
best  to  begin  the  treatment  by  touching  it  up  with  a 20 
per  cent,  solution  of  nitrate  of  silver  and  then  apply  the 
shields. 

Before  nursing  the  shield  is  removed,  the  nipple  washed 
with  boric  solution,  and  a glass  nipple-shield  applied. 


DISEASES  OF  THE  BREASTS 


315 


(See  Fig.  76.)  To  get  the  infant  to  nurse  with  this 
shield  it  is  well  to  fill  it  with  sterile  water  before  inverting 
it  over  the  nipple.  The  child  sucks  out  the  water  and  the 
milk  follows.  The  teterelle  may  also  be  used.  Should 
the  milk  start  with  difficulty,  a hot  application  will  bring 
it  to  the  surface. 

Sometimes  the  above  treatment  fails,  although  the 
author  is  very  seldom  thus  disappointed.  In  these 
cases  he  uses  astringents,  and  the  best  is  nitrate  of 
silver.  The  nipple  is  washed  with  a 2 per  cent,  solution 
of  it  morning  and  evening,  and  it  is  allowed  to  dry  in,  in 
the  sunlight. 

If  the  fissure  is  a deep  one,  the  child  should  be  kept 
from  that  breast  for  a few  days.  In  this  time,  with  the 
nitrate  of  silver  application  and  the  leaden  shields,  the 
fissure  will  have  healed  sufficiently  to  allow  nursing  with 
the  glass  shield  or  the  teterelle. 

It  is  not  necessary  to  say  here  that  extreme  asepsis 
must  be  practised  to  keep  these  cracks  from  being  in- 
fected; the  glass  nipple  shields  must  be  boiled  twice  a 
day,  and  when  not  in  use  should  be  kept  in  saturated 
boric  solution.  They  are  placed  in  this  solution  only 
after  thorough  rinsing  inside  and  out  with  scalding  water. 
Milk  curdles  in  the  folds  of  the  rubber,  and  for  its  removal 
the  rubber  needs  to  be  turned  inside  out. 

Among  the  hundreds  of  remedies  for  cracked  nipples, 
only  compound  tincture  of  benzoin,  glycerin,  glycerin 
with  boric  acid,  collodion,  collodion  with  antiseptics, 
castor  oil  and  bismuth,  and  alcohol  need  be  mentioned. 
They  may  be  used  as  succedanea.  A dressing  of  70 
per  cent,  alcohol  applied  for  four  hours  a.  m.  and  p.  m. 
sometimes  cures  when  the  other  remedies  fail. 

Mastitis. — Inflammation  of  the  mammary  gland  or 
the  tissues  about  it  is  called  mastitis.  There  are  four 
varieties.  The  inflammation  may  be  in  the  skin  around 


3 16  COMPLICA  7I0NS  OF  THE  PUERPERIUM 


the  nipple,  or  a little  abscess  may  form  in  one  of  the 
tubercles  of  Montgomery.  The  inflammation  may  be 
in  one  or  more  lobes  of  the  gland  the  so-called  paren- 
chymatous form,  or  glandular  mastitis.  If  the  inflam- 
matory process  occurs  in  the  fat  and  loose  tissue  between 
the  lobes,  we  speak  of  periglandular  cellulitis  or  phleg- 
monous mastitis,  and  if  the  infection  travels  beneath  the 
gland  to  the  connective  tissue  which  fastens  the  mamma 
to  the  chest-wall,  we  find  pus  under  the  gland,  and 
speak  of  submammary  abscess.  This  is  very  serious 
and,  fortunately,  rare.  The  commonest  is  the  paren- 
chymatous variety,  and  it  is  the  most  amenable  to 
treatment. 

The  cause  of  all  these  forms  is  infection.  Germs 
obtain  access  to  the  gland  and  set  up  inflammation. 
The  different  varieties  spoken  of  are  made  by  the  dif- 
ferent routes  which  the  germs  travel  before  they  cause 
the  inflammation.  Normally,  many  breasts  contain 
germs,  but  these  are  either  naturally  harmless  or  they 
require  special  conditions  to  make  them  virulent.  Such 
conditions  are  cracks,  fissures,  ulcers  of  the  nipple,  bruis- 
ing of  the  breasts,  either  by  too  brisk  massage  or  other 
injury,  too  much  pumping  of  the  breasts,  squeezing  of  the 
breasts,  and  efforts  to  get  them  to  secrete  milk  when  they 
cannot  do  it.  It  is  a question  if  simple  milk  stasis  causes 
abscess.  Surely  engorgement  itself  does  not.  Over- 
stimulation  of  the  breast  may  result  in  infection  and 
abscess.  Infection  is  often  carried  directly  to  the  breasts 
on  the  fingers  of  patient  or  nurse  from  the  lochia,  from 
an  infected  umbilicus,  or  from  any  source  of  infection. 
As  a rule,  these  cases  may  be  prevented  by  proper  pro- 
tection of  the  organ  and  continual  watchfulness  in  avoid- 
ing infection.  If  there  are  cracks  or  fissures,  asepsis  must 
be  especially  thorough,  as  it  is  here  that  the  infection 
usually  gains  entrance. 


DISEASES  OF  THE  BREASTS  3 1 J 

Symptoms. — The  symptoms  of  mastitis  are  pain  in 
the  affected  breast,  and  particularly  in  one  spot,  and  ten- 
derness and  swelling  of  the  same;  there  may  be  a chill, 
and  there  is  nearly  always  fever,  which  may  reach  105° 
F.  The  pulse  is  high,  and  we  observe  all  the  manifesta- 
tions of  a febrile  attack — headache,  malaise,  pains  in  the 
bones,  hypersensitiveness  to  light,  etc  The  part  of  the 
breast  that  is  inflamed  is  hot  and  tender,  and  later  may  be 
reddened.  If,  under  treatment,  the  fever  and  other 
symptoms  abate  within  forty-eight  hours,  one  may  feel 
encouraged  that  an  abscess  will  not  form  If  the  fever 
remains  high  for  more  than  two  days,  one  will  have  to 
fear  this  outcome.  With  proper  treatment  the  prognosis 
is  good.  In  almost  all  cases  an  abscess  can  be  prevented. 

Treatment. — As  soon  as  the  nurse  detects  the  first 
signs  of  inflammation  of  the  breast  she  notifies  the  attend- 
ing physician,  and  until  he  comes  she  withholds  entirely 
the  child  from  the  breast,  and  applies  a very  tight  breast- 
binder.  The  physician  may  order  ice  applications. 
These  must  usually  be  kept  up  constantly  for  forty- 
eight  hours.  Two  large  ice-bags  are  applied  to  each 
breast  and  they  are  kept  half-full,  so  that  they  be  not 
too  heavy  on  the  chest  (Fig.  163).  The  breasts  are 
supported  by  the  binder,  and  the  ice-bags  lie  directly 
on  this,  not  separated  trom  the  skin  by  enough  cloth 
to  prevent  the  cold  from  reaching  the  gland  (Fig. 
164).  The  skin  must  feel  really  cool  to  the  touch, 
or  no  good  is  being  derived  from  the  ice.  If  the  patient 
becomes  chilly,  a hot-water  bag  is  applied  to  the  feet 
and  the  arms  are  wrapped  in  flannel.  A saline  cathartic 
is  usually  ordered,  and  the  liquids  in  the  diet  are  re- 
stricted. With  these  measures  the  inflammation  almost 
always  subsides  without  suppuration.  The  ice-bags 
are  removed  one  by  one  after  the  patient  has  had  a 
normal  temperature  for  twelve  hours.  The  child  is  put 


3 1 8 COMPLICATIONS  OF  THE  PUERPERIUM 


Fig.  163. — Breasts  covered  with  ice-bags.  A thin  gauze  binder  over  all  holds  the 
bags  in  place. 


DISEASES  OF  THE  BREASTS 


319 


back  to  the  breast  twenty-four  hours  after  the  fever  is 
gone  and  at  least  six  hours  after  the  last  ice-bag  is  re- 
moved. 

The  nurse  may  be  asked  if  the  milk  will  not  perma- 
nently dry  up  if  the  child  does  not  nurse  for  several  days. 
Experience  shows  that  it  does  not.  Even  non-pregnant 
women  can  start  the  breasts  to  secrete  milk  by  putting 
a vigorous  infant  to  the  nipple.  A maid  who  was  given 
the  care  of  an  infant  at  night  kept  it  quiet  by  letting  it 


ICE  - BAGS.  .. 


Fig.  164. — Schematic  section  of  body,  showing  relation  of  ice-bags  to  breasts. 

suck  on  the  nipple.  Milk  appeared  and  she  wet-nursed 
the  child.  The  same  occurrence  was  noticed  in  a woman 
forty-nine  years  old  whose  daughter  died  in  labor.  She 
suckled  the  child,  although  her  bosom  had  not  been 
pressed  by  an  infant  for  fourteen  years. 

No  massage  or  pumping  of  the  breasts  is  allowable  at 
any  time  during  the  treatment  of  mastitis.  Should  an 
abscess  form,  the  condition  being  shown  by  irregular 
temperature,  chills,  and  softening  and  redness  of  the 


320  COMPLICATIONS  OF  THE  PUERPERIUM 


inflamed  portion  of  the  breast,  the  nurse  will  be  required 
to  prepare  for  operation — that  is,  for  draining  the  breast. 
Ordinary  surgical  rules  are  observed  here;  repetition  is 
not  necessary.  After  the  abscess  is  opened  the  nurse, 
having  to  dress  it,  should  be  careful  not  to  carry  the 
infection  to  the  woman’s  genitals  or  to  the  baby’s  navel. 
Rubber  gloves  should  be  used  for  dressing  the  breast. 


Fig.  165. — Bier’s  congestion  treatment  of  mastitis. 

Suppuration  is  often  prolonged,  and  there  may  be  a suc- 
cession of  abscesses,  fairly  riddling  the  breasts  and  dis- 
figuring them.  In  addition,  the  general  health  may  suffer, 
therefore  in  these  prolonged  cases  the  nurse  will  arrange 
for  a generous  diet,  outside  living,  and  all  the  factors 
making  for  rapid  recuperation. 

The  latest  treatment  of  mastitis  is  the  “congestion 
therapy”  of  Bier.  A large  dome-shaped  glass  is  in- 


DISEASES  OF  THE  FEE  A STS  32  I 

verted  over  the  breast  and  the  air  exhausted  from  it  by 
means  of  a pump  (Fig.  165).  The  bell  is  applied  sev- 
eral times  a day  for  thirty  minutes.  The  physician  must 
be  asked  for  accurate  instructions  regarding  its  use. 

Galactorrhea,  or  Excess  of  Milk. — This  is  not  a 
common  condition,  and  when  it  occurs,  is  seldom  per- 
sistent. After  a few  weeks  the  activity  subsides  to  a 
normal  that  is  sufficient  for  the  infant.  If  the  clothing 
is  soiled  by  the  constant  leakage  of  milk,  sufficient  pads 
or  a glass  reservoir  shield  should  be  placed  to  catch  the 
overflow,  and  a snug  breast-binder  should  be  constantly 
worn.  The  patient  should  reduce  the  amount  of  water 
drunk  and  of  starches  eaten.  The  bowels  should  be 
moved  daily  by  saline  cathartics.  The  infant  should  be 
put  to  the  breasts  less  often,  and  regularity  is  to  be  in- 
sisted on.  Medicines  are  sometimes  given  to  check  the 
secretion  of  milk.  These  are  belladonna  and  iodid  of 
potassium.  The  nurse  should  watch  for  their  physiologic 
effects,  as  some  women  have  an  idiosyncrasy  for  them. 

Agalactia,  or  Scarcity  of  Milk.  -This  condition  is 
much  more  common  than  galactorrhea.  It  is  little  less 
than  a calamity  when  a woman  is  unable  to  nurse  her 
child.  That  a woman  should  refuse  to  nurse  her  infant 
when  she  has  milk  and  is  well  is  unpardonable. 

Unfortunately,  a large  number  of  women  cannot  nurse, 
either  because  of  ill  health  or  because  they  have  no 
milk.  Many  children  die,  either  directly  of  the  want  of 
mother’s  milk,  or  indirectly  of  children’s  diseases  to  which 
they  fall  easy  prey  if  they  have  been  brought  up  by  the 
bottle.  The  custom  of  giving  children  to  wet-nurses  or 
to  others  to  be  brought  up  on  the  bottle  is  an  ancient 
one.  Caesar  reproached  the  Roman  women  for  doing  it 
and  for  squandering  their  affection  on  dogs  and  monkeys. 

The  writer  has  noticed  a decided  improvement  among 
women  in  regard  to  nursing  their  children. 

21 


322 


COMPLICATIONS  OF  THE  PUERPERIUM 


Causes.  ^The  causes  of  deficient  milk-supply  are 
general  weakness  or  ill-health,  worry,  lack  of  nourish- 
ment, a puny  baby,  malformation  of  the  breasts  or  the 
nipples,  and  absence  of  gland  tissue.  In  the  last  class 
of  cases  the  breasts  may  be  large  with  fat  deposit.  If 
there  is  no  gland  tissue,  it  is  useless  and  dangerous  to  try 
to  stimulate  the  secretion  of  milk. 

Symptoms.  -The  symptoms  of  deficient  milk-supply 
are:  first,  the  distress  of  the  child — its  loss  in  weight; 
second,  the  pain  in  the  breasts  and  the  absence  of  secre- 
tion. , The  child  is  unsatisfied  with  the  nipple;  he  may 
suck  for  a short  while,  but,  finding  nothing  there,  will 
refuse  it  and  cry.  After  supplemental  feeding  he  goes 
to  sleep.  When  there  is  plenty  of  milk,  the  mother  can 
feel  it  leave  the  breast  and  see  the  infant  swallow.  There 
are  also  some  drops  of  “white  nourishment”  around  the 
mouth.  These  are  all  absent  in  agalactia.  Weighing 
the  child  before  and  after  nursing  proves  the  func- 
tioning of  the  breast.  If  the  mother  persists  in  nursing 
after  the  supply  has  diminished,  the  act  comes  to  be 
attended  with  pain  in  the  breasts,  radiating  around  to  the 
back,  first  only  during  the  nursing,  later  in  the  intervals 
also.  Unless  nursing  is  interrupted,  serious  inroads  on 
the  woman’s  health  may  result. 

Treatment. — If  there  is  not  enough  milk  in  the  breasts 
an  attempt  may  be  made  to  stimulate  the  secretion  by 
diet,  cool  baths,  and  massage  of  the  breasts.  Medi- 
cines have  very  uncertain,  if  any,  action.  Pituitrin 
has  recently  been  tried,  also  thyroid  extract.  The 
physician  may  prescribe  a malt  extract,  somatose,  or 
other  preparation  vaunted  to  stimulate  the  secretion. 
The  author’s  experience  with  malt  preparations  is  that 
they  often  fatten  the  patient  and  dry  up  the  milk. 

By  increasing  the  liquids  in  the  diet  the  total  quantity 
of  milk  may  sometimes,  not  always,  be  increased.  When 


DISEASES  OF  THE  BREASTS 


323 


the  milk-supply  is  not  augmented,  the  patient  puts  on 
fat.  The  patient  is  given  milk  in  large  quantities,  water, 
very  weak  tea,  chocolate,  oatmeal  and  barley  gruels,  and 
oyster-stews,  in  addition  to  her  regular  diet.  The  effect 
is  not  permanent,  and  too  much  water  thins  the  blood. 
Alcoholic  drinks  should  be  restricted  or,  better,  avoided, 
and  certainly  by  a mercenary  wet-nurse.  Alcoholics 
are  not  good  for  the  infant. 


Fig.  166. — Massage  of  breast  to  stimulate  the  flow  of  milk:  First  motion. 


Cool  full  baths  stimulate  the  skin  and  the  breasts  also. 
They  may  be  taken  daily  and  at  about  8o°  to  84°  F. 
The  whole  body  should  be  briskly  rubbed  with  a coarse 
towel,  avoiding  the  mammae. 

Bier’s  method  of  producing  artificial  engorgement  has 
been  applied  to  the  breast  to  stimulate  the  flow  of  milk. 
The  results  thus  far  have  been  fair. 

Massage  of  the  breasts  stimulates  the  formation  of 
milk.  When  massaging  the  breasts  for  this  purpose  the 


324  COMPLICATIONS  OF  THE  PUERPERIUM 

rules  given  on  pages  309-310  do  not  apply.  One  wishes 
here  to  irritate  the  gland.  This  is  done  by  raising  the 
whole  breast  from  the  chest  wall  (Fig.  166)  and  working 
it  gently  between  the  fingers.  Care  should  be  used  not 
to  bruise  the  delicate  organ,  as  an  abscess  may  result. 
The  gland  is  then  held  against  one  hand,  while  the  tips 
of  the  outspread  fingers  of  the  other  hand  make  circular 
movements  all  around  its  periphery  (Fig.  167). 


Fig.  167. — Massage  of  breast  to  stimulate  the  flow  of  milk:  Second  motion. 


Electricity  has  been  tried,  with  indifferent  success.  The 
best  stimulant  for  the  milk  secretion  is  a vigorous  infant. 

One  should  not  be  discouraged  too  soon,  as  the  estab- 
lishment of  the  milk  secretion  is  sometimes  slow.  In 
one  case  sufficient  milk  diet  did  not  come  until  the  fifth 
month.  Often  after  the  patient  is  up  and  gets  outdoors 
the  milk  comes  in  large  quantities.  One  may  be  misled 
to  believe  that  this  is  the  action  of  some  special  drug 
or  of  feeding. 


DISEASES  OF  THE  BREASTS 


325 


If,  however,  the  measures  instituted  have  no  effect,  it  is 
wiser  to  discontinue  them  as  soon  as  this  fact  is  apparent. 
Too  great  zeal  in  forcing  the  breasts  to  act  may  result  in 
mastitis.  The  milk  secretion  has  been  known  to  cease 
completely  on  a sudden  fright  experienced  by  the  woman, 
and  it  has  been  observed  that  a quiet,  placid  life  con- 
tributes to  a normal  and  continued  flow  of  milk. 

Abnormal  Milk.  Remarkable  as  it  may  seem,  the 
milk  of  the  mother,  although  plentiful,  may  not  agree 
with  the  child.  The  writer  has  seen  cases  where  it 
seemed  to  act  like  an  irritant  intestinal  poison,  and  fatal- 
ities have  even  been  reported.  These  cases  have  all 
been  neurotic  mothers,  and  most  of  them  in  the  higher 
classes.  Chemic  and  microscopic  examinations  have 
not  given  satisfactory  explanations.  The  condition  may 
or  may  not  recur  in  the  subsequent  pregnancies. 

The  child  will  refuse  the  breast,  in  which  case  the  milk 
may  have  a foreign  taste,  or  it  will  vomit  the  ingested 
milk  or  have  a diarrhea  from  it,  sometimes  with  fever. 
The  milk  may  appear  yellower  and  thicker  in  these  cases, 
showing  either  a persistence  of  the  colostrum  or  an  in- 
crease in  fat  and  protein — that  is,  it  is  too  rich.  Curi- 
ously, sometimes  a child  will  refuse  one  breast  and  accept 
the  other;  in  a case  of  this  kind  the  milk  of  one  breast 
was  said  to  be  salty. 

If  the  milk  is  believed  to  disagree  with  the  child, 
causing  green,  acrid  stools,  the  nursing  should  be  dis- 
continued for  forty-eight  hours,  the  breasts  being  regu- 
larly emptied  in  the  meantime  by  the  breast-pump. 
The  child  is  fed  on  a substitute  milk,  and  at  the  end  of 
this  period  another  trial  is  made  of  the  mother’s  milk. 
If  it  again  causes  intestinal  disturbance,  the  wisest 
course  to  pursue  is  to  obtain  a wet-nurse  for  the  child. 

If  the  mother’s  milk  is  deficient  in  one  or  the  other  in- 
gredient, the  physician  will  instruct  the  nurse  to  add  this 


326  COMPLICATIONS  OF  THE  PUERPERIUM 

or  that  preparation  of  sugar,  cream,  barley-water,  etc., 
to  each  feeding. 

Drying-  Up  the  Milk.  -When  it  is  necessary  to  dry 
up  the  milk,  the  physician  will  usually  instruct  the  nurse 
to  bind  the  breasts  up  as  tightly  as  the  woman  can  toler- 
ate it,  to  reduce  the  liquids  in  her  diet,  and  to  give  her 
daily  a saline  cathartic.  Before  applying  the  binder  the 
breasts  thould  be  emptied  by  a strong  infant  or  breast- 
pump,  and  sterilized  with  soap  and  water  and  a bichlorid 
solution.  The  binder  is  not  disturbed  unless  the  phys- 
ician wishes  an  ointment,  of  which  belladonna  is  the 
favorite,  applied.  Systemic  effects  have  been  observed 
from  belladonna  ointment  applied  to  the  breasts. 

Experience  has  shown  that  it  is  better  to  leave  the 
breasts  entirely  alone  after  the  above  treatment,  and  not 
to  massage  or  pump  them. 

Care  of  a Wet-nurse. — If  the  mother  cannot  nurse 
her  babe,  a wet-nurse  should  be  recommended.  The 
family  may  not  be  able  to  employ  one,  or  it  may  be  im- 
possible to  obtain  a suitable  one,  but  the  fact  stands  out 
that  the  best  nourishment  for  a newborn  babe  is  mother’s 
milk,  and  no  effort  should  be  spared  to  provide  the  same. 
Only  the  two  reasons  given  above  ought  to  be  allowed  in 
the  discussion  of  the  engagement  of  a wet-nurse.  The 
author  is  aware  that  a wet-nurse  at  all  times  is  not  an 
unalloyed  blessing,  and  sometimes  even  an  almost  in- 
tolerable nuisance,  but  the  family  should  be  encouraged 
to  bear  with  much  for  the  sake  of  the  infant.  After  a 
few  months,  when  the  child  has  gotten  a good  start,  the 
wet-nurse  may  be  dispensed  with — if  really  necessary. 

The  physician  will  select  the  woman,  and  having  satis- 
fied himself  that  she  is  healthy  and  has  good  milk,  has 
no  syphilitic  or  nervous  disorders,  will  ask  the  nurse  to 
look  after  her.  The  wet-nurse  on  arrival  should  be 
received  quietly,  allowed  to  bathe,  and  should  then  rest 


DISEASES  OF  THE  BREASTS 


327 


a few  hours  in  bed.  This  is  to  quiet  the  usual  excite- 
ment and  perhaps  alarm  occasioned  by  her  new  surround- 
ings. The  nurse  can  do  much  to  make  her  feel  at  home. 
The  first  milk  of  the  breast  is  pumped  out,  and,  after 
the  woman  has  rested,  the  child  is  allowed  to  nurse. 
The  milk  may  be  scanty  for  a day  or  so,  probably  because 
of  the  mental  disturbance  alluded  to. 

A wet-nurse  should  do  light  work  about  the  house, 
and  she  must  take  exercise  out-of-doors.  The  nurse 
takes  care  that  she  is  cleanly  about  her  person,  her  teeth 
perfect,  that  her  bowels  are  kept  in  good  order,  and  that 
she  has  sufficient  sleep.  Anything  abnormal  in  these 
matters  should  be  reported  to  the  physician. 

The  diet  is  important.  Let  the  woman  have  those 
things  to  which  she  has  been  accustomed.  If  a woman 
who  is  accustomed  to  brown  bread,  soup-meat,  and  pota- 
toes is  allowed  to  eat  rich  pastries,  fried  meats,  and  heavy 
sauces,  she  will  put  on  fat  and  the  milk  will  dry  up.  The 
cook  is  to  be  instructed  not  to  allow  the  wet-nurse  to  eat 
indigestibles  and  acids,  as  these  affect  the  milk.  It  is 
fatuous  to  try  to  keep  the  milk  by  plying  the  wet-nurse 
with  beer,  malt  extracts,  rich  foods,  liquids,  etc.  If  the 
milk  is  increased  in  amount,  the  quality  is  bad.  A 
change  of  wet-nurses  is  needed.  Should  the  woman  men- 
struate, there  is  apt  to  be  some  slight  disturbance  of  the 
infant’s  bowels,  but  usually  not  sufficient  to  contra- 
indicate nursing.  All  these  precautions  are  particularly 
needed  in  the  case  of  a premature  infant.  If  plain  living, 
with  light  household  duties,  a moderate  amount  of 
exercise  out-of-doors,  and  a quiet,  undisturbed  life  do  not 
give  a good  milk-supply,  another  wet-nurse  is  to  be 
selected. 


CHAPTER  V 


THE  DISORDERS  OF  THE  FIRST  WEEKS  OF 

LIFE 

There  are  many  conditions  which  arise  during  the 
first  weeks  of  life — some  mild,  some  serious — which  the 
nurse  ought  to  know.  She  has  often  to  diagnose  them 
and  report  them  to  the  physician.  It  is  well  that  she  be 
acquainted  with  some  of  the  methods  of  treatment, 
although  in  the  individual  case  she  obtains  directions 
from  the  physician. 

AFFECTIONS  OF  THE  DIGESTIVE  ORGANS 

Indigestion  heads  the  list  in  frequency  of  disorders 
of  digestion.  The  causes  are  too  frequent  nursing, 
irregular  feeding,  letting  the  child  drink  too  much  or  too 
fast,  inappropriate  food,  especially  common  in  artificially 
fed  children,  and  exposure  to  cold.  Overfeeding  and 
overdrinking  are  very  common.  Indigestion  is  a symp- 
tom of  intestinal  infection. 

The  symptoms  are  restlessness,  colic,  vomiting,  diar- 
rhea, rumbling  in  the  bowels  (borborygmus),  discharge 
of  gas  by  mouth  or  rectum,  and  excoriations  around  the 
anus.  The  stools  are  green,  acrid,  foamy,  and  contain 
much  mucus  and  clumps  of  undigested  milk.  There 
may  be  a little  fever. 

The  treatment  consists  in  removing  the  causes  men- 
tioned. The  physician  may  prescribe  pepsin  or  other 
remedies,  beginning  the  treatment  with  15  drops  of 
castor  oil.  He  may  order  food  withheld  for  a short 

328 


AFFECTIONS  OF  THE  DIGESTIVE  ORGANS  329 

period,  and  barley-  or  rice-water  substituted.  The  nurse 
regulates  the  hygiene  of  the  infant,  but  gives  neither 
drugs  nor  household  remedies  without  instructions. 

Colic  is  one  of  the  symptoms  of  indigestion,  al- 
though it  may  occur  when  the  stomach  and  bowels  are 
acting  well  It  is  due  to  similar  causes — errors  in 
amount,  quality,  and  time  of  the  feedings.  A bottle-fed 
baby  almost  never  escapes  many  attacks  of  colic,  and 
breast-fed  infants  not  seldom  suffer  from  it.  It  seems  as 
though  the  intestinal  canal  requires  time  to  get  into  sys- 
tematic action.  If  the  child  is  not  kept  warm,  it  is 
likely  to  suffer  from  colic. 

Symptoms  of  colic  are  crying,  with  drawing  up  of  the 
feet;  often  the  child  is  awakened  from  sleep  by  colic, 
when  it  emits  a short,  sharp  cry;  rumbling  in  the  bowels 
and  passage  of  gas  by  the  rectum,  whereupon  the  colic 
ceases;  and  the  symptoms  of  indigestion,  if  this  is  causa- 
tive. 

The  treatment  of  the  colic  should  begin  with  the  re- 
moval of  the  cause — that  is,  regulation  of  the  diet,  a cath- 
artic for  constipation,  and  warm  clothing,  especially  about 
the  feet  and  abdomen.  Household  remedies  in  great 
numbers  are  given  by  nurses,  but  it  is  better  to  avoid 
them  and  get  orders  from  the  physician.  If  the  nurse  is 
alone,  she  may  give  the  child  a salt  solution  colonic 
flushing.  Then  it  is  laid  on  a warm- water  bag  for  a while 
or  cuddled  up  warmly  against  the  nurse’s  breast.  A 
drink  of  hot  water,  plain  or  with  a few  drops  of  essence 
of  peppermint,  is  given.  The  nurse  must  not  give  a 
child  whisky,  paregoric,  or  other  drug  without  express 
permission.  The  writer  found  a case  where  the  nurse 
had  been  giving  the  babe  creme  de  menthe  until  the 
little  one  was  a toper. 

Gastric  lavage  is  sometimes  ordered  for  colicky  babies, 
as  well  as  many  medicines,  of  which  calomel  and  the 


330  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 


aromatics  are  the  commonest.  Opium  is  used  with  great 
circumspection  in  infants. 

Difficulty  in  Nursing.  -The  causes  of  difficulty  in 
nursing  are:  ignorance,  the  babe  must  learn  to  suck; 
tongue-tie,  cleft  palate,  and  hare-lip;  occlusion  of  the 
nasal  passages,  impeding  breathing;  sore  mouth,  as 
thrush  and  Bednar’s  aphthae;  diseases  of  the  lung,  as 
pneumonia,  bronchitis,  atelectasis;  diseases  of  the  brain, 
causing  apathy  and  coma;  prematurity,  the  infant  feels 
no  hunger  and  may  “ sleep  away.”  The  breast  itself  may 
be  at  fault;  the  nipples  may  be  too  small  or  depressed; 
the  gland  may  be  so  engorged  that  the  babe  cannot  take 
hold;  the  milk  may  not  agree,  having  perhaps  a foreign 
taste;  or  there  may  be  no  milk  there. 

With  the  cause  the  nurse  will  have  the  remedy. 

Vomiting. — This  is  a symptom  of  many  diseases, 
but  principally  of  indigestion  and  gastro-enteritis.  In- 
fants normally  vomit  in  the  first  weeks,  and  it  may  be 
due  to  overfilling  of  the  stomach  or  to  the  fact  that  the 
stomach  is  situated  favorably  for  regurgitation  at  this 
tender  age.  Only  when  the  vomiting  is  persistent  and 
attended  with  evident  nausea  or  contains  bile,  blood,  etc., 
is  the  symptom  significant.  There  may  be  a pyloric 
stenosis  or  mechanical  occlusion  of  the  lower  gut,  in 
which  case  constipation  will  accompany  the  emesis.  The 
treatment  of  vomiting  is  nil  unless  there  is  a real  sick- 
ness behind  it.  The  child  may  nurse  a little  shorter 
period  than  fifteen  minutes,  and  should  be  handled  care- 
fully afterward.  If  the  child  should  vomit  blood,  bile, 
or  anything  but  milk,  the  nurse  must  notify  the  doctor 
at  once. 

Constipation.  -Newborn  infants  are  seldom  costive, 
although  in  later  months  this  is  not  uncommon.  In  the 
first  days  the  bowels  may  not  move  because  a plug  of 
tough  mucus  has  accumulated  in  the  rectum  (Fig.  168). 


AFFECTIONS  OF  THE  DIGESTIVE  OR  G A NS  33 1 


After  this  is  gotten  rid  of  the  evacuations  occur  normally. 
In  the  first  days,  too,  the  bowels  may  not  move  because 
the  anus  is  absent.  This  is  a very  serious  condition,  and 
requires  operation;  it  should  be  re- 
ported to  the  physician  without 
delay.  In  these  cases  the  infant 
soon  commences  to  vomit,  but  the 
general  health  is  interfered  with  only 
late.  Constipation  may  be  due  to 
insufficient  food,  to  a lack  of  water, 
and  to  habit. 

The  treatment  consists  of:  first, 
regulation  of  the  diet,  colonic  flush- 
ings, the  use  of  castor  oil  or  other 
laxative;  later,  massage.  Glycerin 
and  soap  suppositories  are  not  rec- 
ommended. Gluten  suppositories 
and  oil  enemata  may  be  used  as  in 
the  adult.  After  the  cord  is  off  and 
the  navel  healed,  light  abdominal 
massage  is  practised.  Cathartics 
may  be  given  the  mother  to  act  on 
the  child  through  the  milk. 

Diarrhea. — This  is  much  more 
frequent  in  the  first  weeks  than 
constipation,  and  is  more  difficult 
to  cure.  The  ingestion  of  the  colos- 
trum causes  a physiologic  diarrhea, 
it  being  evidently  nature’s  object  to  get  rid  of  the 
meconium  in  this  way  as  soon  as  possible  after  birth. 
The  writer  has  found  that  children  do  better  if  this 
tarry  material  is  early  gotten  rid  of,  and,  therefore,  pre- 
scribes for  all  babies  10  drops  of  castor  oil  on  the  second 
day.  If  the  milk  is  too  rich  in  fats  or  proteins  the  infant 
may  have  a diarrhea,  and  if  the  mother  is  taking  laxa- 


Fig.  168. — Plug  of  mu- 
cus from  the  rectum  of  a 
newborn  child.  Upper 
part  stained  by  meco- 
nium. 


332  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 


tives  the  child  feels  their  effects.  Oftenest  diarrhea  is 
caused  by  gastro-intestinal  infection,  and  then  is  usu- 
ally attended  by  fever.  Occasionally  the  infant  has 
frequent  watery  movements  of  a yellow  color  and 
normal  odor,  and  does  not  apparently  suffer.  These 
cases  are  not  serious,  simply  being  due  to  indigestion, 
and  will  get  well  if  the  child  is  made  to  nurse  more 
slowly,  and  if  the  milk  is  diluted  a little — for  example, 
by  giving  some  barley-water  before  the  nursing.  Often 
the  condition  of  the  bowels  will  not  be  satisfactory  until 
the  mother  is  up  and  out-of-doors.  This  seems  to  regu- 
late the  function  of  the  mammary  glands. 

Green  Stools. — The  nurse  should  inspect  and  note 
the  character  of  the  child’s  evacuations.  If  they  are  ab- 
normal, the  doctor  ought  to  know  it.  Normally  the 
stools  are  dark  green  for  two  days,  then  brownish, 
then  with  the  addition  of  yellow,  and  soon  all  golden 
yellow. 

If  the  meconium  is  a long  time  in  coming  away,  castor 
oil  should  be  given  to  clear  the  intestinal  tract,  as  this 
material  is  prone  to  decompose.  If  the  child  does  not 
obtain  enough  food,  the  stools  are  scanty  and  brownish 
until  the  deficiency  is  supplied. 

The  stools  should  be  semisolid,  and  the  water  margin 
around  the  solid  part  should  be  about  J inch  wide. 
There  should  be  no  lumps  or  curds;  the  odor  is  that  of 
sour  milk — not  offensive.  There  is  very  little  mucus — 
not  enough  to  give  a glossy  appearance — and  the  move- 
ment should  not  be  frothy.  If  the  stools  are  green, 
slimy,  frothy,  and  full  of  whitish  lumps,  the  child  has  in- 
digestion. If  the  stools  are,  in  addition,  sharp,  with  a 
strong  odor,  and  if  the  child  has  fever,  an  inflammation 
in  the  gastro-intestinal  tract  is  present.  In  these  cases 
the  movements  are  so  sharp  and  acrid  that  the  buttocks 
and  perineum  of  the  infant  are  eroded,  even  ulcerated. 


AFFECTIONS  OF  THE  DIGESTIVE  OF  G A NS  333 

Such  stools  and  such  ulcerations  are  decidedly  more 
common  with  bottle-fed  infants.  The  nurse,  in  treating 
such  a case,  after  following  the  physician’s  orders,  may 
seek  to  improve  the  condition  of  the  mother  by  providing 
mental  quiet,  good  air  and  food,  and  regularity  of  feed- 
ing and  nursing  the  baby. 

Medicines,  of  which  calomel  is  a favorite,  are  often 
given  to  correct  the  abnormal  intestinal  conditions. 

If  blood  appears  in  the  stools  the  case  is  called  melena 
neonatorum.  The  blood,  unless  in  large  amounts,  is 
dark — almost  black.  The  red  color  comes  out  if  the 
napkin  is  wet  with  water.  The  nurse  will  notify  the 
physician  at  once,  as  the  condition  is  serious. 

Inanition  Fever. — In  the  first  days,  before  the  milk 
comes,  the  infant  may  have  a sudden  rise  of  temperature 
— sometimes  as  high  as  105°  F.,  usually  not  over  103°  F. 
In  marked  cases  there  are  severe  cerebral  symptoms,  even 
convulsions.  The  writer  is  very  skeptical  about  these 
cases  being  due  to  starvation  or  thirst,  but  thinks  that, 
more  likely,  they  are  due  to  bowel  infection.  Treatment 
consists  of  giving  15  drops  of  castor  oil,  a saline  solution 
colonic  flushing,  much  water  to  drink,  and  mother’s 
milk.  Cool  bathing  for  the  fever  or  an  ice-bag  to  the 
head  may  be  needed  should  cerebral  symptoms  develop. 

Thrush  or  Sprue. — This  is  an  affection  of  the  mouth, 
due  to  the  growth  of  a vegetable  fungus  on  the  mucous 
membrane.  The  fungus  is  called  Saccharomyces  albi- 
cans or  Monilia  albicans,  and  may  readily  be  seen  under 
the  microscope.  The  tongue,  gums,  and  inside  of  the 
cheeks  are  covered  with  a whitish  pellicle,  in  spots  or 
larger  plaques,  which  cannot  be  as  easily  wiped  off  as  can 
milk,  but  when  rubbed  hard  leaves  a bleeding  surface. 

Thrush  is  due  to  uncleanliness.  It  may  be  favored  by 
poor  health,  and,  therefore,  is  commoner  in  weak,  sickly, 
and  premature  infants,  but  it  is  always  due  to  neglect  of 


334  disorders  of  the  first  weeks  of  life 


the  mouth,  and  should  not  occur.  In  weak  and  prema- 
ture infants  thrush,  by  interfering  with  the  nourishment, 
and  in  rare  cases  by  growing  down  into  the  stomach,  may 
be  the  direct  cause  of  death. 

The  treatment  requires  persistence  and  care,  especially 
in  premature  infants.  After  each  feeding  the  mouth 
should  be  washed  with  saturated  solution  of  borax,  not 
boric  acid.  A piece  of  cotton  is  wrapped  around  the 
little  finger,  saturated  with  the  solution,  and  with  this  the 
surface  is  gently  gone  over,  removing  all  loose  material. 
A daily  application  of  a 2 per  cent,  nitrate  of  silver  solu- 
tion will  hasten  the  cure.  After  the  application  of  silver 
nitrate  2 drops  of  castor  oil  are  put  in  the  mouth  to 
allay  the  irritation.  A weak  peroxid  solution  is  also 
helpful.  No  sugar  preparations  or  honey  are  to  be  used, 
and  care  is  necessary  to  avoid  hurting  the  delicate  mouth. 

Bednar’s  Aphthae.  Far  back  in  the  mouth,  where 
the  lower  jaw  is  connected  with  the  upper  jaw  and  where 
the  cheek  runs  into  the  pharynx,  is  stretched  a ligament. 
Over  this  ligament  the  mucous  membrane  is  very  thin, 
and  in  appearance  white.  If  the  nurse,  when  cleaning 
the  mouth,  rubs  too  hard  at  the  back  of  the  cheek,  she 
will  rub  off  the  delicate  epithelium  over  the  ligament 
mentioned  and  produce  a superficial  ulcer — perhaps  one 
on  each  side.  These  ulcers,  called  Bednar’s  aphthae, 
interfere  with  nursing  because  they  are  painful,  and  they 
may  lead  to  infection,  with  fever  and  serious  illness. 
Prophylactically,  the  nurse  will  use  only  the  gentlest 
force  in  cleansing  the  mouth.  A daily  application  of  2 
per  cent,  nitrate  of  silver  to  the  ulcer  is  a very  efficient 
remedy. 

Marasmus. — This  term  is  used  to  designate  those 
cases  of  simple  but  obstinate  wasting  in  infants.  Pro- 
nounced cases  of  marasmus  do  not  occur  as  early  as  the 
period  with  which  we  are  dealing,  but  among  premature 


AFFECTIONS  OF  THE  RESPIRATORY  TRACT  335 


infants  marasmus  is  one  of  the  greatest  dangers.  The 
autopsies  on  children  dead  of  marasmus  show  very  little 
that  is  characteristic,  yet  the  main  symptom  of  the 
disease,  excessive  and  continual  wasting  of  the  whole 
body,  shows  that  the  whole  organism  is  profoundly 
affected. 

The  disease  is  due  to  errors  of  nourishment,  and  there- 
fore occurs  almost  invariably  in  bottle-fed  infants. 
It  seems  that  such  children  cannot  thrive  on  anything 
but  the  natural  food,  and  will  waste  away  and  die  in 
spite  of  the  best  care  and  most  expert  preparation  of 
other  foods.  It  must  also  be  borne  in  mind  that  when 
an  infant  has  actually  begun  to  be  marantic  from  im- 
proper nourishment,  it  may  be  difficult  or  impossible  to 
get  it  to  assimilate  even  mother’s  milk.  There  is  a strong 
hint  in  this  fact — not  to  waste  too  much  time  in  trying 
various  foods,  but  if  not  speedily  successful  in  getting 
suitable  nourishment,  to  provide  mother’s  milk  at  any 
cost. 

The  symptoms  of  marasmus  are  those  of  simple  wast- 
ing: loss  of  weight,  until  the  little  body  is  almost  skin 
and  bone,  protuberant  belly,  loss  of  appetite,  indigestion, 
and  extreme  susceptibility  to  all  diseases,  which  take  on 
a very  fatal  character. 

Treatment  may  be  summed  up  as  follows:  mother’s 
milk  and  fresh  air  with  sunlight. 

AFFECTIONS  OF  THE  RESPIRATORY  TRACT 

Fortunately,  newborn  infants  seldom  suffer  with  se- 
vere pneumonia,  bronchitis,  etc.,  but  a child  may  easily 
take  cold  unless  proper  care  is  observed,  and,  once 
started,  a catarrh  is  not  easy  to  cure. 

Snuffles  is  usually  due  to  a slight  rhinitis  of  innocent 
nature,  but  it  may  be  due  to  a constitutional  taint 
(syphilis),  and  the  symptom  should  at  once  be  reported 


336  DISORDERS  OE  THE  FIRST  WEEKS  OF  LIFE 


to  the  physician.  If  it  is  attended  with  a skin  eruption, 
a blood  disease  is  all  the  more  probable. 

For  a simple  coryza,  a little  warmed  oil  placed  in  the 
nostrils  and  rubbing  the  bridge  of  the  nose  with  cam- 
phorated oil  are  sufficient.  The  condition  disappears  in 
a few  days.  Care  is  indicated  in  order  to  prevent  the 
inflammation  from  going  down  into  the  lungs.  The 
infant  should  be  kept  warm  and  not  be  allowed  to  get 
chilled  when  being  changed  or  oiled.  The  bath  had  bet- 
ter be  omitted  for  a few  days. 

Bronchitis  and  Pneumonia.  -In  young  infants  in- 
flammation of  the  bronchial  tubes  is  a serious  matter, 
because  pneumonia  is  so  prone  to  develop.  The  causes 
are  usually  infection  by  the  air  or  by  aspirating  infectious 
vaginal  secretions  during  delivery.  Children  delivered 
by  operations  are  much  more  likely  to  develop  pneu- 
monia. Treatment  is  entirely  symptomatic.  The  phys- 
ician may  order  stimulants,  of  which  carbonate  of  am- 
monia is  a favorite.  Oxygen  may  be  employed.  Nar- 
cotics are  usually  rejected  as  dangerous.  The  wet-pack 
is  the  best  means  of  reducing  temperature.  The  nurse 
wrings  a soft  diaper  out  of  water  at  a temperature  speci- 
fied by  the  physician — usually  from  85°  to  90°  F. — and 
wraps  it  loosely  around  the  chest.  Over  it  comes  one 
layer  of  soft  flannel.  This  pack  remains  in  place  two 
hours,  when  it  may  be  renewed.  The  cool  bath  may  also 
be  used  to  reduce  temperature.  The  water  should  be 
ioo°  F.  at  the  start,  and  be  reduced  to  94 0 F.  while  the 
infant  is  immersed.  The  bath  should  not  last  over  five 
minutes.  While  in  the  bath  the  child  must  be  watched 
for  symptoms  of  shock.  If  weakened  at  all,  a little 
whisky  on  the  tongue  and  a warm- water  bag  are  needed. 
The  mainstay  in  the  treatment  is  mother’s  milk.  With- 
out it  few  children  recover.  The  child  must  be  held  in 
the  arms  a great  deal,  and  its  position  frequently  changed 


AFFECTIONS  OF  THE  URINARY  ORGANS  33 7 

—this  to  prevent  the  blood  from  stagnating  in  the  lungs. 
The  air  in  the  room  must  be  warm,  moist,  and  fresh. 
Only  good  nursing  will  save  these  little  sufferers. 

Cyanosis,  or  Blue  Babies.  When  a child  is  born 
with  congenital  heart  disease,  or  when  the  wall  between 
the  two  sides  of  the  heart  does  not  close  fully,  the  blood 
is  not  completely  oxygenated  in  the  lungs,  and  the  skin 
of  the  infant  remains  bluish  or  cyanotic.  The  hands  and 
feet  are  cold.  This  disease  has  been  called  morbus 
caeruleus.  These  children  may  grow,  but  they  die 
young,  being  extremely  susceptible  to  outward  influences, 
as  overexertion,  indigestion,  the  eruptive  fevers,  etc. 
Occasionally  apparent  recovery  occurs. 

There  is  a condition  in  newborn  infants,  more  common 
in  cases  of  prematurity,  where  the  lungs  do  not  unfold 
and  expand  as  they  should.  This  is  called  atelectasis, 
and  is  very  fatal.  The  children  are  blue,  as  the  ones 
just  described,  but  the  condition  is  more  quickly  fatal. 
In  either  case  if  the  child  survives  it  becomes  a narrow- 
chested  weakling. 

Treatment  is  tonic  in  either  case,  and  later  on  sys- 
tematic efforts  are  to  be  made  to  develop  the  chest  by 
graduated  muscular  exercise  and  by  all  kinds  of  athletic 
sports  to  strengthen  the  heart.  These  must  be  taken 
under  the  control  of  a physician,  to  avoid  overdoing  it. 
Injurious  influences  should  be  held  from  the  growing 
child,  such  as  violent  exercise,  violent  emotions,  excess 
in  diet,  and  extreme  heat  and  cold. 

AFFECTIONS  OF  THE  URINARY  ORGANS 

Delayed  Urination.  -The  nurse  may  notice  that  the 
infant  does  not  urinate  for  a day  or  so  after  delivery,  and 
inspection  of  the  parts  gives  no  reason  for  it.  This  delay 
is  more  common  after  operative  deliveries,  when  the 
child  has  fever  or  jaundice,  in  the  children  of  primiparae, 

90 


338  DISORDERS  OF  THE  FIRST  WE  FA'S  OF  LIFE 

and  in  premature  infants.  If  the  parts  are  normal,  no 
alarm  need  be  felt.  The  babe  sometimes  passes  water 
in  the  bath,  and  since  the  urine  is  colorless,  this  is  not 
observed,  or  the  stain  on  the  diaper  is  likewise  not  seen. 
The  physician  may  order  a diuretic  medicine,  as  sweet 
spirit  of  niter  (spiritus  aetheris  nitrosi),  and  ask  the 
nurse  to  give  the  child  a great  deal  of  warm  water  to 
drink.  As  aids  may  be  used  a moist  warm  dressing 
around  the  pelvis  and  warm  stupes  to  the  abdomen  and 
kidneys.  A warm  sitz-bath  may  be  given.  The  cathe- 
ter is  rarely  required.  If  the  anuria  is  prolonged,  the 
physician  may  pass  the  catheter  to  assure  himself  that 
the  passage  is  free.  Spontaneous  cure  is  the  rule. 

Uric  Acid.  -The  napkins  of  the  newborn  are  not  in- 
frequently found  to  be  stained  with  urine  containing  little 
reddish  or  brownish  crystals.  These  are  composed  of 
uric  acid  or  of  urates,  and  indicate  that  the  urine  is  con- 
centrated. These  salts  are  occasionally  found  deposited 
in  the  kidneys.  A free  flow  of  urine  washes  them  out 
on  to  the  napkin.  The  child  may  cry  with  a little  pain 
as  the  sharp  crystals  are  passing.  The  symptom  is 
similar  in  cause  and  significance  to  the  anuria  just  con- 
sidered, and  requires  the  same  treatment. 

Phimosis.  In  boys  the  orifice  of  the  prepuce  is 
sometimes  so  small  that  the  urine  cannot  readily  escape, 
causing  the  infant  pain  and  difficulty  in  urination. 
There  is  actual  danger  in  this  condition,  because,  since 
the  skin  cannot  be  retracted,  the  secretions  decompose 
underneath  and  serious  inflammation  may  result.  The 
physician  may  dilate  the  preputial  opening,  he  may  in- 
cise it  so  as  to  allow  the  retraction  of  the  skin,  or  he  may 
perform  the  operation  of  circumcision. 

Circumcision. — Among  orthodox  Jewish  families  the 
ritual  circumcision  is  performed  when  the  child  is  eight 
days  old. 


AFFECTIONS  OF  THE  URINARY  ORGANS  339 


The  nurse  may  see  the  ancient  ceremony  in  all  its  in- 
teresting details  performed  by  the  ordained  circumcisor — 
the  “Mohel.”  The  anesthetic  employed  is  whisky  and 
water  1:4,  with  a little  sugar  added.  A bit  of  soft  cake 
is  wrapped  in  a corner  of  a handkerchief,  tied  with  thread, 
wet  with  the  whisky,  and  given  the  child  to  suck  a few 
minutes  before  and  during  the  operation. 

The  nurse  will  often  be  shocked  by  the  lack  of  asepsis 
practised.  Little  can  be  done  by  the  nurse  to  avoid  in- 
fection of  the  wound,  which  not  seldom  occurs,  although 
it  is  rare  for  the  infant  to  die.  Many  infants  have  died 
from  hemorrhage.  If,  as  often  happens,  the  ceremony  is 
made  the  occasion  of  a large  “party,”  the  nurse  must 
see  that  the  mother  is  kept  free  from  excitement  and  too 
many  visitors.  Even  in  families  that  have  dropped  the 
stricter  orthodox  beliefs  the  circumcision  is  practised, 
but  the  physician  almost  always  performs  the  operation. 

The  nurse  will  make  the  usual  preparations  for  minor 
surgery  Only  scissors,  rat-toothed  forceps,  and  a few 
artery  clamps  are  necessary.  Stitches  may  or  may  not 
be  used.  The  anesthetic  used  by  the  “Mohels”  may  be 
employed,  and  the  infant  will  usually  sleep  several  hours 
afterward,  by  which  time  the  initial  pain  is  gone. 

It  would  be  well  for  the  nurse  to  have  a styptic  powder 
of  dried  alum  in  readiness,  as  sometimes  there  is  obstinate 
hemorrhage. 

The  infant  is  wrapped  warmly  and  laid  on  its  back, 
with  the  thighs  flexed  on  the  belly,  and  held  by  the 
nurse  with  hands  covered  by  a sterile  towel.  The  child 
must  be  held  firmly,  because,  though  simple,  the  opera- 
tion is  delicate.  The  basin  of  hand  solution  and  instru- 
ments are  arranged  conveniently  as  shown  in  Fig.  169. 

The  first  dressing,  which  may  be  moist  or  dry,  accord- 
ing to  individual  operators,  should  be  left  on  six  or  eight 
hours.  The  nurse  must  watch  carefully  for  secondary 


340  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 


Fig.  169. — Infant  prepared  for  circumcision.  Nurse  stands  on  the  left.  On  the  right  is  a euchre  table,  protected  with 
newspaper  and  sterile  towel,  holding  basin  of  weak  antiseptic  solution  and  the  instruments.  The  nurse’s  hands  are  covered  by  a 
sterile  towel. 


AFFECTIONS  OF  THE  SKIN 


341 


hemorrhage.  To  remove  dressings,  they  must  first  be 
soaked  with  sterile  water.  For  the  first  two  days  the 
part  is  covered  with  a moist  1 per  cent,  boric  acid  dress- 
ing. After  this  a little  vaselin  may  be  used.  Care 
should  be  taken  to  allow  no  gauze  to  adhere  to  the  glans, 
and  the  diaper  must  be  arranged  so  as  to  exert  no  com- 
pression. 

Should  there  be  secondary  hemorrhage,  the  nurse 
should  wrap  the  organ  tightly  with  gauze  powdered 
with  dry  alum,  and  notify  the  physician  at  once.  Until 
he  arrives  the  nurse  can  exert  constant  circular  com- 
pression and  thus  prevent  serious  loss  of  blood.  Heal- 
ing takes  place  in  from  three  to  seven  days,  and  the  child 
may  be  peevish  and  fretful  until  the  source  of  irritation 
has  disappeared. 

Dilatation. — Some  physicians  make  a routine  practice 
of  dilating  the  prepuce  and  drawing  it  behind  the  glans 
as  a part  of  the  daily  toilet  of  the  child.  It  may  be 
necessary  first  to  incise  the  edge  of  the  orifice  before  the 
skin  will  go  back.  After  the  first  retraction  the  nurse 
will  be  instructed  to  carry  out  the  procedure.  This  is 
done  by  slowly  slipping  the  skin  back  toward  the  pubis 
until  the  whole  glans  is  exposed.  Smegma  is  now  cleaned 
off  with  vaselin,  and  the  skin  brought  forward  again.  A 
lubricant  is  always  applied. 

AFFECTIONS  OF  THE  SKIN 

Jaundice. — A yellowish  discoloration  of  the  skin  in 
newborn  infants,  called  icterus  neonatorum,  in  milder  or 
severer  gradations,  is  present  in  fully  40  per  cent,  of  cases. 
It  appears  from  the  third  to  the  sixth  day,  and  affects  the 
whole  body.  There  are  several  theories  as  to  its  cause, 
as  disorganization  of  the  blood,  inefficiency  of  the  liver, 
causing  an  accumulation  of  bile  in  the  blood,  sepsis,  etc. 
The  writer  believes  that  the  worst  forms  are  due  to  sepsis. 


342  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

In  the  milder  cases  the  child  is  unaffected,  but  when 
the  skin  is  very  yellow,  especially  if  the  whites  of  the 
eyes  are  icteric,  the  general  health  of  the  infant  suffers. 
In  some  cases  eyen  the  secretions  from  the  nose,  eyes, 
and  other  orifices  are  yellow.  The  bowels  are  usually 
out  of  order,  and  the  infant  gains  slowly.  The  physician 
may  prescribe  medicines,  but  the  nurse’s  duties  will  con- 
sist in  providing  an  assured  and  adapted  nourishment  for 
the  child,  and  giving  colonic  flushings  to  clear  the  bowel 
and  to  stimulate  excretion  of  the  bile  by  way  of  the 
kidneys  and  skin.  The  mother  should  be  assured  that 
the  jaundice  will  fully  disappear. 

Eruptions  on  the  Skin.  -The  skin  of  newborn 
babies  is  not  always  clear  and  smooth  at  birth.  The 
writer  has  seen  infants  born  with  blisters  from  pin-head 
to  finger-nail  size  and  with  raised  eruptions  of  various 
kinds.  The  skin  of  some  infants  desquamates  completely 
after  birth,  the  epithelium  coming  off  in  large  or  small 
flakes.  The  epithelium  may  loosen  in  the  palms  of  the 
hands  in  a large  piece,  and  the  nurse  will  need  to  use  care 
in  removing  it. 

Later  the  skin  may  desquamate  as  the  result  of  fevers, 
or  from  intestinal  disorders  or  toxemia,  and  the  scaling 
much  resembles  that  of  scarlatina. 

Vesicular  Eruptions. — Tiny  water-blisters  on  a red 
base,  occurring  closely  set  around  the  forehead,  neck, 
and  in  the  body  folds,  are  due  to  sweating  and  to  too 
warm  clothing,  or  to  a tender  skin  after  the  use  of  water 
or  soap  and  water.  This  is  popularly  called  “red  gum.” 
If  there  is  no  redness  around  the  vesicles,  the  term  “white 
gum”  is  applied.  The  scientific  name  for  the  affection 
is  strophulus  (this  has  nothing  to  do  with  scrofula)  or 
miliaria.  Prickly  heat  is  the  same  affection,  but  in  an 
aggravated  form,  with  inflammation  around  the  vesicles. 

All  three  are  caused  by  the  sweat-glands  being  oc- 


TREATMENT 


343 


eluded,  allowing  the  sweat  to  accumulate  under  the 
closed  openings  of  the  glands  in  the  skin.  They  all 
cause  the  infant  more  or  less  discomfort,  but  most  dis- 
tress comes  from  prickly  heat. 

Sometimes  the  blisters  run  together  and  form  blebs,  or 
they  may  become  pustular,  when  the  case  is  not  simple, 
as  above  described,  but  belongs  to  a class  of  skin  infec- 
tions some  of  which  are  serious  and  contagious. 

An  eruption  of  irregular,  reddish-brown  spots  with 
uneven  borders,  fading  to  a copper  color,  is  strongly 
suggestive  of  blood  taint  in  the  infant.  If  with  this  the 
child  has  snuffles,  and  if  the  region  around  the  anus  is 
reddened,  eroded,  and  cracked,  the  suspicion  of  syphilis 
is  grounded.  The  nurse  must  exercise  constant  pre- 
caution that  she  does  not  infect  herself  through  the 
child. 

Chafing,  or  Bcsema  Intertrigo.— In  fat  babies  the 
skin  in  the  folds  is  likely  to  macerate  and  become  irri- 
tated. A watery  exudation  occurs,  which  may  decom- 
pose and  cause  little  abscesses.  This  is  especially 
common  in  bottle-fed  infants. 

Treatment 

The  treatment  of  all  these  affections,  except  that  of 
constitutional  eruptions,  is  based  on  the  principles  of 
absolute  cleanliness  and  dryness  of  the  affected  skin. 

For  the  heat-rashes  the  child  should  be  dressed  in  the 
lightest  clothes,  and  on  hot  days  left  partly  undressed, 
out  of  the  way  of  drafts,  for  short  periods  during  the 
greatest  heat.  The  bath  may  be  employed  without  soap, 
and  the  skin  thoroughly  dried  without  rubbing.  The 
cloth  is  laid  on  the  skin  and  the  fingers  are  rubbed  over 
it.  Then  stearate  of  zinc  powder  is  applied  to  the 
affected  parts.  Finest  powdered  rice  starch  is  also  good. 
Powders  containing  boric  acid  should  not  be  used. 


344  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

Boric  acid  powder  irritates  the  skin.  For  the  intertrigo 
the  same  treatment  is  employed,  and  the  folds  are  kept 
apart  with  a thin  layer  of  cotton  or  old  linen,  which  is  fre- 
quently changed.  In  some  cases  water  acts  as  a direct 
irritant  and  must  be  discontinued ; this  should  always  be 
done  if  the  affection  proves  rebellious  to  treatment. 
Any  other  measure  will  be  ordered  by  the  physician. 
All  eruptions  should  be  noted  on  the  record-sheet  and 
shown  to  the  physician. 

It  must  be  remembered  that  insect-bites,  irritating 
dye-stuffs,  or  insufficiently  washed  clothes  may  cause 
eruptions  on  the  delicate  skin  of  newborn  babes. 

OTHER  AFFECTIONS  OF  THE  NEWBORN  INFANT 

Enlargement  of  the  Breasts.— A few  weeks  after 
birth  the  nurse  may  notice  that  the  breasts  of  the  infant 
are  enlarged.  They  may  contain  milk,  which  the  old 
German  midwives  called  “Hexenmilch,”  or  witches’ 
milk.  This  engorgement  of  the  breasts  disappears  un- 
treated. If  the  nurse  rubs  the  surface  too  roughly  or 
tries  to  squeeze  the  milk  out,  she  may  bruise  the  delicate 
organ  and  cause  an  abscess.  In  girls  this  is  a very  serious 
matter,  as  the  gland  is  thus  destroyed  and  the  function 
of  nursing  rendered  impossible. 

Treatment.  —The  breasts  are  bathed,  carefully 
anointed  with  camphorated  oil,  padded  lightly  with  cot- 
ton, and  a smooth  little  breast-binder  is  applied  and 
sewed  on.  This  lies  undisturbed  for  five  days,  when  the 
engorgement  will  have  disappeared.  During  the  neces- 
sary handling  of  the  infant,  the  fact  of  the  breasts  being 
engorged  should  be  borne  in  mind  and  the  region  not 
touched. 

If  an  abscess  forms,  which  is  quite  unusual  under  this 
treatment,  it  should  be  opened  speedily  to  prevent  com- 
plete destruction  of  the  gland.  The  physician,  there- 


OTHER  AFFECTIONS  OF  THE  NEWBORN  INFANT  345 

fore,  ought  to  be  apprised  daily  of  the  condition  of  the 
infant. 

Vulvitis. — In  female  infants  a moderate  inflamma- 
tion of  the  vulva  may  exist,  and  there  may  be  consider- 
able mucous  discharge.  No  treatment  save  cleanliness, 
care  to  avoid  injury,  and  the  application  of  albolene  is 
necessary. 

Menstruation. — Once  in  about  50  cases  of  female 
infants  a bloody,  apparently  menstrual,  discharge  ap- 
pears on  the  napkin.  In  one  case  it  was  so  profuse  that 
the  little  one’s  health  was  affected.  She  was  listless  and 
limp  for  a few  days.  The  bloody  discharge  almost  never 
means  anything  pathologic,  but  it  may,  and  should, 
therefore,  be  promptly  reported.  Treatment  is  usually 
unnecessary.  In  the  case  cited,  1 drop  of  ergot  was 
given  three  times. 

Delayed  Separation  of  the  Cord. — In  puny  chil- 
dren and  in  cases  where  the  cord  was  large  and  thick, 
or  where  a hemorrhage  occurred  near  its  insertion,  the 
process  of  gangrene  and  separation  of  the  cord  is  very 
slow  and  may  be  delayed  beyond  two  weeks. 

The  falling  of  the  cord  may  be  hastened  by  simple 
means.  A little  collar  of  cotton  is  made  and  saturated 
with  95  per  cent,  alcohol  and  placed  around  the  base  of 
the  stump,  which  is  then  dressed  as  usual.  Another 
method  is  to  paint  the  stump  and  its  insertion  with  2 
per  cent,  nitrate  of  silver.  Only  in  rarest  cases  is  it 
necessary  to  snip  the  remaining  strands  of  tissue  with 
scissors  (aseptic). 

Granulations  of  the  Navel. — These  sometimes 
form  and  cause  a continual  watery  discharge,  at  times 
bloody,  from  the  depressed  surface.  To  cure  them  early, 
wiping  with  2 per  cent,  nitrate  of  silver  suffices;  later 
they  may  have  to  be  ligated  and  cut  off. 


346  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

INFECTIONS  OF  THE  NEWBORN 

A child  is  sometimes  infected  before  it  leaves  the 
womb  by  bacteria  floating  in  the  blood  of  the  mother, 
but  for  practical  purposes  we  consider  the  infant,  when 
born,  sterile.  Being  an  aseptic  medium,  it  is  at  once 
attacked  by  germs  from  all  sides.  These  germs  gain 
entrance  through  the  mouth,  the  eyes,  the  navel,  the 
vulva,  and  any  accidental  wound.  The  little  one  is  very 
susceptible  to  infection,  and  if  these  germs  are  at  all 
virulent,  they  may  overcome  the  slight  resistance  it  offers 

The  duty  of  the  nurse,  therefore,  is  mainly  to  pre- 
vent infection  of  the  newborn.  The  principle  of  this 
prevention  is:  asepsis  of  all  things  coming  in  contact 
with  the  eyes,  the  mouth,  the  navel,  the  genitals,  and 
accidental  wounds.  Of  course,  those  surfaces  exposed 
to  air  will  be  contaminated  by  air-infection,  but  in  pri- 
vate practice  this  danger  is  minimal,  although  in  general 
hospitals,  where  pus  is  present,  it  must  always  be  con- 
sidered. The  fingers  of  the  nurse  may  be  soiled  by 
lochial  discharges  or  from  handling  bed-pans  or  other 
non-sterile  articles,  and  without  proper  disinfection  she 
may  dress  the  navel  or  wash  the  mouth.  The  clothes 
of  the  infant  may  have  been  mixed  with  infected  linen, 
the  rubber  nipples  and  other  utensils  used  by  the  infant 
when  feeding  may  not  have  been  boiled,  the  milk  may  be 
impure — indeed,  the  sources  of  infection  are  innumerable. 

Infection  of  the  Umbilicus. — The  stump  of  the 
cord  separates  in  two  ways — by  dry  and  by  moist  gan- 
grene. Dry  gangrene  is  the  normal  method.  Moist 
gangrene  is  the  quicker,  but  more  dangerous,  and  is  ab- 
normal. Infection  of  the  stump  and  at  the  line  of  union 
of  the  stump  and  abdomen  shows  itself  by  redness, 
edema,  swelling  of  the  skin,  and  an  unhealthy  appear- 
ance under  the  edge  of  the  cord,  even  to  the  presence  of 
a few  drops  of  pus.  There  may  be  an  odor  to  the  cord, 


PLATE  III 


The  cord  stump  has  dropped  off, 
the  base  is  covered  with  pink  granu- 
lations, now  being  covered  with 
epithelium. 


Infected  umbilicus.  Fourth 
day.  Note,  area  of  swelling 
and  redness,  the  pus  and  the 
moist  stump  of  cord. 


INFECTIONS  OF  THE  NEWBORN 


347 


and  the  child  may  have  fever,  which  may  reach  103°  F. 
In  severer  cases  the  navel  may  ulcerate,  or  an  inflamma- 
tion may  extend  more  or  less  over  the  belly,  or  the  in- 
fection travels  along  the  vessels  inside  the  abdomen  until 
the  liver  is  involved,  and  general,  fatal  blood-poisoning 
results.  The  importance  of  asepsis  of  the  navel  may, 
therefore,  be  appreciated  by  the  nurse.  If  there  are  any 
signs  of  inflammation  about  the  navel,  the  nurse  will  re- 
port it  to  the  physician.  He  may  make  tiny  incisions 
into  the  inflamed  area  for  drainage,  and  then  apply  a wet, 
weak,  antiseptic  dressing — 50  per  cent,  alcohol  is  some- 
times used.  Antiseptic  powders  are  preferred  by  some 
physicians.  Should  the  cord  become  moist,  with  an 
appreciable  odor,  the  nurse  must  correct  the  condition 
early,  as  it  may  lead  to  graver  infection.  The  stump  is 
wrapped  in  cotton,  saturated  with  50  per  cent,  alcohol, 
and  then  dressed  as  usual.  Every  eight  hours  this 
dressing  is  renewed,  and  three  dressings  will  ordinarily 
suffice.  Antiseptic  powders,  as  boric  acid,  salicylic  acid, 
iodoform,  and  starch,  are  occasionally  employed. 

Infection  of  the  Byes,  or  Ophthalmia  Neona- 
torum.— Ophthalmia  neonatorum  is  an  acute  purulent 
inflammation  of  the  mucous  membrane  of  the  eyes  of  the 
newborn.  While  a few  other  germs  may  be  causative, 
the  most  common  cause  is  the  gonococcus  of  Neisser,  or 
the  gonorrhea  germ  (Fig.  170).  It  gains  access  to  the 
eyes  from  the  vagina  while  the  infant  is  passing  through, 
or  it  is  wiped  into  the  eyes  by  the  nurse  or  doctor  when 
the  infant  is  given  its  first  attention  (the  bath,  etc.),  or 
it  is  allowed  to  get  in  during  the  first  days  of  life  from  an 
infected  bath-tub  or  the  finger  of  the  nurse,  or  perhaps 
the  mother  herself  while  the  child  is  being  handled. 

In  whatever  way  the  germ  gains  entrance,  it  quickly 
sets  up  a violent  inflammation  of  the  conjunctiva.  At 
first  the  lids  grow  red,  then  there  is  a thin,  irritating  dis- 


348  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

charge,  with  yellowish  flakes.  After  a few  hours  this  be- 
comes purulent  and  the  lids  become  so  swollen  that  the 
eyes  are  closed  (Plate  IV).  Unless  active  and  constant 
treatment  is  instituted,  the  inflammation  gains  headway, 
the  cornea  may  ulcerate  away,  and  the  whole  eye  be  de- 
stroyed One-third  of  the  blindness  in  the  world  is 
caused  by  this  dreadful  affection,  and  it  is  primarily 
venereal  in  origin.  If  ever  a nurse  has  the  opportunity 
to  show  of  what  she  is  capable,  now  is  the  time.  Really 


Fig.  170. — Diplococcus  of  Neisser,  the  gonorrhea  germ,  taken  from  the  pus  of 

the  eye. 

at  least  two  nurses  are  demanded  in  a case  of  ophthalmia. 
Treatment  must  be  unremitting,  and  each  order  of  the 
doctor  must  be  punctually  carried  out. 

Prevention. — If  a woman  is  known  to  have  gonorrhea, 
or  if  there  is  a foul  discharge,  the  doctor  may  wish  the 
vagina  douched  antiseptically  several  times  during  labor, 
and  extra  care  taken  that  nothing  gets  into  the  eyes  at 
any  time.  In  all  cases  directly  the  head  is  born  the  face 


PLATE  IV 


Acute  ophthalmia  neonatorum. 


INFECTIONS  OF  THE  NEWBORN 


349 


is  wiped  with  pledgets  squeezed  dry  out  of  a weak  bi- 
chlorid  or  lysol  solution;  then  the  lids  may  be  opened, 
and  warm  boric  solution  allowed  to  flush  out  the  con- 
junctival sacs.  After  this,  the  Crede  method,  or  some 
equally  reliable  method  of  prevention,  is  used.  If  a 
case  occurs  or  is  suspected  in  a nursery  where  there  are 
other  children,  the  infant  is  to  be  isolated  at  once,  sepa- 
rate utensils  used  for  it,  its  clothes  disinfected  before 
being  sent  to  the  laundry,  and  the  nurse  should  not 
touch  anything  that  will  be  used  for  the  other  infants. 

Treatment.  In  the  first  stage  of  the  disease  the  phys- 
ician may  order  ice  applied  to  the  eyes.  If  only  one  eye 
is  affected,  the  nurse  protects  the  other  one  by  covering 
it  with  cotton  and  holding  this  in  place  with  adhesive 
plaster.  The  arms  of  the  baby  must  be  bound  down 
to  the  sides,  so  that  infection  may  not  be  carried  by  them. 
The  covered  eye  should  be  inspected  every  four  hours  for 
evidences  of  beginning  infection. 

The  application  of  ice  to  the  eyes  is  shown  in  Fig.  171. 
A large  piece  of  pure  ice  is  placed  in  a sterile  basin  and 
saturated  solution  of  boric  acid  is  poured  over  it.  Bits  of 
sterile  cotton  the  size  and  shape  of  a 5 -cent  piece  are 
moistened  in  the  boric  solution  and  laid  on  the  ice  to  cool. 
The  infant  is  placed  on  a warm- water  bag,  then  on  a pillow 
on  a table,  and  snugly  covered  up.  The  nurse  then  seats 
herself  comfortably  at  the  head,  and  places  the  ice-cold 
pledgets  on  the  lids,  changing  them  every  minute,  and 
throwing  the  waste  into  a paper  bag  at  the  side.  The  order 
may  be  to  keep  up  the  application  of  cold  for  twenty-four 
hours  and  not  to  interrupt  it  while  the  child  is  nursing. 

The  secretions  must  be  frequently  removed  from  under 
the  lids,  because  they  are  very  acrid  and  erode  the  deli- 
cate cornea.  This  is  the  great  danger  of  the  disease. 
For  removing  the  pus  from  the  eye  the  best  method  is  a 
stream  of  saline  solution  or  boric  solution.  The  nurse 


350  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

arranges  things  as  in  Fig.  172.  In  the  can  or  douche- 
bag  is  the  solution  as  ordered,  of  a temperature  of  about 
70°  F.  The  bag  hangs  20  inches  above  the  infant’s 
head,  and  the  tube  is  armed  with  an  ordinary  medicine- 
dropper  tip,  with  a large  opening.  The  force  of  the 
water  must  not  be  too  great.  The  nurse  arranges  the 


Fig.  17 1. — Arrangement  for  application  of  ice  to  the  eyes. 


child  on  her  lap  on  a rubber  drainage-sheet  leading  into 
a bucket.  The  left  hand  steadies  the  child;  the  right 
holds  the  point  in  the  fingers,  wdiile  the  ball  of  the  hand 
rests  on  the  side  of  the  infant’s  head,  pressing  it  gently 
against  the  knee,  thus  steadying  it.  The  point  is  directed 
at  the  inner  corner  of  the  lower  eye,  so  that  the  force  of 
the  stream  washes  everything  from  under  and  from  the 


INFECTIONS  OF  THE  NEWBORN 


351 


inner  corner  of  the  lid  outward.  The  infant  usually  opens 
the  eye  under  the  gentle  force  of  the  stream,  but  if  it 
does  not,  the  left  hand  may  be  used  to  separate  the  lids. 
Some  nurses  find  it  more  convenient  to  place  the  infant 


Fig.  172. — Arrangement  for  irrigation  of  the  eyes.  The  pledget  in  the  left 
hand  is  placed  against  the  cheek  to  prevent  the  fluid  from  getting  into  the 
nostrils  and  mouth. 


on  a table,  as  in  Fig.  171,  for  the  eye  irrigation.  These 
irrigations  may  be  needed  for  weeks  or  even  months. 

The  physician  may  make  applications  of  nitrate  of 
silver  to  the  lids,  or  may  prescribe  the  newer  remedies, 
protargol  or  argyrol.  Atropin  is  sometimes  used  to 


352  DISORDERS  OF  THE  EIRST  WEEKS  OF  LIFE 


dilate  the  pupil,  and  the  nurse  should  watch  for  its  toxic 
effects.  Conscientious  nursing  alone  will  save  the  light 
of  day  for  the  babe. 

Care  of  the  Nurse  Herself.  During  all  this  prolonged 
course  of  treatment  the  nurse  should  protect  herself  from 
infection.  This  is  done,  first,  by  never  touching  her  own 
eyes  during  the  treatment  of  such  a case  without  pre- 
vious thorough  sterilization  of  the  hands;  second,  avoid- 
ing spattering  solutions,  used  for  irrigation,  on  her  person 
or  dress. 

Infection  of  the  Mouth  and  Throat. — One  of 

these,  thrush,  has  already  been  considered.  The  gono- 
coccus may  infect  the  throat,  and  the  child  may  have  a 
pharyngitis  due  to  streptococci.  The  writer  has  noticed 
pharyngitis  with  fever  more  commonly  in  general  hos- 
pitals that  accept  maternity  cases.  Cases  are  reported 
where  the  infection  invaded  the  Eustachian  tube,  the 
middle  ear,  and  thus  reached  the  brain.  A strepto- 
coccic septicemia  may  result  from  gastro-intestinal 
infection. 


HEMORRHAGES  IN  THE  NEWBORN 

Quite  a number  of  children  are  lost  at  a very  early 
period  of  life  through  hemorrhage.  This  is  a subject  of 
which  little  is  positively  known.  The  newborn  may 
have  more  or  less  profuse  hemorrhage  from  the  bowels — 
the  so-called  melena  neonatorum,  so  named  because  the 
blood  is  black;  there  may  be  hematemesis;  hemorrhage 
from  the  navel;  from  all  mucous  surfaces,  or  into  the 
skin.  The  child  may  be  a “bleeder.”  The  nurse  can 
do  nothing  but  compress  a bleeding  spot  favorably  situ- 
ated until  medical  aid  can  be  obtained.  The  physician 
may  order  gelatin  administered,  or  calcium  chlorid  or 
saline  solution,  or  perhaps  all  three,  and  the  nurse  should 
make  the  necessary  preparations.  Nowadays  hemor- 


OPERATIVE  INJURIES 


353 


rhage  is  treated  by  the  injection  into  the  child  of  blood 
drawn  from  an  adult,  or  of  human  blood-serum,  or  that  of 
the  horse  or  rabbit. 

OPERATIVE  INJURIES 

During  obstetric  operations  the  nurse  may  marvel  at 
the  amount  of  force  used  by  the  accoucheur,  fearing  that 
both  mother  and  child  may  be  destroyed.  While  it  is 


Fig.  173. — Left  facial  paralysis  following  delivery  by  forceps  (Budin). 


true  that  in  many  cases  both  escape  entirely,  it  is  also 
true  that  in  not  a few  cases  both  mother  and  babe  are 
seriously  and  irreparably  injured.  Bones  of  the  arm 
and  leg  are  not  seldom  broken,  the  skull  may  be  fractured, 
or  a hemorrhage  in  the  brain  may  be  caused  by  difficult 
operative  deliveries.  Minor  injuries  are  pressure-marks 
by  the  forceps  on  the  head  and  face,  facial  paralysis,  and 
bruising  of  the  face,  with  swelling  of  the  eyes.  Infants 
born  in  face  presentation  are  much  disfigured.  The 
23 


354  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 


lips  are  swollen  and  the  face  mottled  with  hemorrhages 
in  the  skin. 

The  facial  paralysis  (Fig.  173),  while  it  distorts  the 
face  a great  deal,  almost  always  disappears  before  the 
end  of  a week.  The  swelling  of  the  eyes  and  face  goes 
down  in  a few  days. 

Pressure-marks  left  by  the  forceps  crust  over  and  dry, 
healing  taking  place  underneath.  If  they  are  deeper, 


Fig.  174. — Showing  how  a caput  succedaneum  is  formed. 

extending  into  the  bone,  a bit  of  skin,  or  even  a bit  of 
bone,  may  ulcerate  off,  with  the  production  of  pus.  The 
antiseptic  care  given  ordinary  surgical  wounds  is  applied 
in  these  cases.  Antiseptic  solutions  should  be  very  weak 
when  applied  to  infants,  as  they  are  susceptible  to  chemic 
poisoning. 

When  the  physician  has  set  broken  bones,  the  nurse 
will  see  that  the  dressings  remain  in  place,  sewing  them 


OPERATIVE  INJURIES 


355 


securely  if  necessary;  that  they  do  not  become  soiled  by 
urine,  vomit,  or  other  discharges;  that  they  do  not  cut 
the  infant  or  cause  chafing,  and  that  the  parts  below  do 
not  swell  from  too  tight  bandaging. 

Injuries  to  the  Brain.  It  is  best  for  the  infant 
if  it  comes  into  the  world  easily,  without  assistance 
from  art.  No  matter  how  skilfully  the  accoucheur  may 
deliver  the  fetus,  his  method  is  brute  force  compared 


Fig.  175. — Double  cephalhematoma.  This  followed  a spontaneous  and  rela- 
tively easy  delivery. 


with  the  smooth  process  of  nature,  and  almost  always 
the  infant  suffers  injury.  True,  this  injury  may  be 
slight,  or  not  even  apparent  at  the  time,  but  evidence 
is  accumulating  that  birth-injuries  lead  to  nervous  dis- 
eases later  in  life,  as  headaches,  imbecility,  epilepsy, 
insanity.  More  light  is  needed  on  this  subject.  Diffi- 
cult operative  deliveries  may  produce  hemorrhages,  small 
or  large,  in  the  brain.  These  may  produce  cyanosis,  con- 


356  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 


vulsions,  and  death  within  a few  days,  or,  if  the  child 
recovers,  permanent  paralysis  remains. 

Caput  succedaneum  is  a swelling  on  the  top  of  the 
newborn  infant’s  head  (Fig.  174),  found  at  birth,  due  to 
the  pressure  and  venous  congestion  it  undergoes  during 
delivery.  The  edema  disappears  in  from  a few  hours  to 
a day. 

Cephalhematoma  is  a blood  tumor  on  the  cranium  of 
the  infant,  lifting  the  periosteum  from  the  bone  (Fig.  175). 
It  appears,  after  a day  or  so,  as  a roundish,  soft,  painless, 
fluctuating  swelling  on  either  side  of  the  head.  Depend- 
ing on  their  size,  cephalhematomata  persist  for  weeks 
or  months,  but  they  will  gradually  be  absorbed.  The 
mother’s  fears  may  thus  be  allayed.  Few  physicians 
operate  in  such  cases. 

CONGENITAL  DEFORMITIES 

It  is  w.ell  that  monstrosities  are  so  seldom  capable 
of  extra-uteiine  existence,  since  they  are  not  uncommon. 


Fig.  176. — Nipple  for  babies  with  cleft  palate  (Starr). 


When  a monster  is  born,  the  nurse  should  not  allow  the 
mother  to  see  it,  and  it  should  be  hidden  from  the  gaze 
of  curious  relatives  or  friends.  The  mother  must  never 
know  she  has  given  birth  to  such  an  infant. 

If  the  child  is  born  with  a harelip  or  a cleft  palate, 
nursing  may  be  so  seriously  interfered  with  that  the 
general  health  may  suffer.  Mucus  accumulates  in  the 


CONGENITAL  DEFORMITIES 


357 


throat  and  may  cause  pneumonia.  To  avoid  this  the 
child  is  to  be  kept  in  a partly  sitting  position.  The 
physician  may  provide  a special  nursing  nipple  for  such 
cases  (Fig.  176),  or  direct  that  the  child  be  fed  by  gavage 
until  strong  enough  to  bear  operation. 

Occlusion  of  the  anus  or  imperforate  anus  the 
nurse  will  discover  when  she  comes  to  take  the  infant’s 
temperature  and  by  the  fact  that  the  bowels  do  not 
move.  The  physician  is  to  be  informed  at  once,  as  an 
operation  must  be  immediately  undertaken  to  make  a 


Fig.  177. — Adhesive  plaster  applied  for  the  cure  of  umbilical  hernia 


passage.  Occasionally  the  bowel  is  occluded  higher  up, 
and  laparotomy  may  be  performed.  The  result  is  al- 
most uniformly  fatal. 

Tongue-tie  is  a very  simple  condition,  but  it  may  be 
the  cause  of  the  child’s  not  nursing  properly,  and  is  often 
overlooked.  The  tip  of  the  tongue  is  attached  to  the 
gum  of  the  lower  jaw  by  a thin  band.  This  should  be 
nicked  at  the  edge  with  scissors,  and  then  torn  back  by 
the  finger-tip.  The  physician  is  to  do  this,  as  there  is 
sometimes  persistent  and  perhaps  dangerous  oozing. 


358  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

Supernumerary  fingers  and  toes  should  be  re- 
moved when  the  child  is  a few  weeks  old. 

Hernia.  Umbilical  hernia  is  quite  common,  and  is 
due  to  imperfection  of  the  abdominal  wall  at  the  navel, 
and  not  to  improper  tying  of  the  cord.  Spontaneous 
cure  is  the  rule,  and  this  may  be  hastened  by  a 2 -inch 
strip  of  adhesive  plaster,  placed  so  as  to  hold  the  navel 
together  from  the  sides  (Fig.  177).  First  the  skin  should 
be  disinfected  and  dried  with  alcohol. 

Inguinal  and  femoral  hernias  are  rare.  Premature 
children  may  have  them.  They  often  heal  spontane- 
ously, although  they  are  more  likely  to  need  a truss  than 
the  navel  hernia.  The  prognosis  is  good. 

SUNDRY  COMPLICATIONS 

Convulsions.-  In  the  first  three  weeks  infants  may 
have  spasms  from  cerebral  injuries  received  during  labor, 
such  as  fracture  of  the  skull  and  hemorrhage  in  the  brain ; 
second,  from  intestinal  disorders  associated  with  a gen- 
eral toxemia;  third,  from  the  so-called  “starvation  fever,” 
which  the  author  believes  is  an  auto-intoxication  or  in- 
fection; fourth,  from  tetanus  or  lockjaw  infection;  fifth, 
from  cerebrospinal  meningitis  the  result  of  infection, 
usually  from  the  navel;  sixth,  from  atelectasis  pulmonum 
— this  is  commoner  in  premature  infants. 

Very  often,  preceding  the  actual  convulsion  the  child 
will  show  premonitory  symptoms.  These  are  twitching 
of  the  muscles  of  the  face  or  extremities,  stiffness  of  the 
jaws  or  of  the  body  (in  tetanus  the  stiffness  of  the  jaw 
is  marked),  refusal  to  nurse,  continual  sucking  or  swal- 
lowing movements,  a staring  expression  in  the  eyes,  and 
a short,  high-pitched,  sharp  cry  without  any  apparent 
cause  for  it.  When  the  nurse  observes  these  things,  or 
if  she  is  surprised  by  the  actual  spasm,  she  will  inform 
the  physician  at  once.  Little  can  be  done  until  he 


SUNDRY  COMPLICATIONS 


359 


arrives.  Should  the  infant  stop  breathing  after  the  con- 
vulsion, or  if  the  cyanosis  is  too  prolonged,  a warm  full 
bath  may  be  given  and  a few  drops  of  diluted  whisky 
poured  down  the  infant’s  throat.  Oxygen,  if  at  hand, 
may  be  administered. 

The  physician  may  order  sedative  medicines,  as  bromid 
and  chloral,  and  ice  to  the  head. 

lockjaw,  or  tetanus,  is  due  to  infection,  usually 
of  the  navel,  with  the  tetanus  bacillus.  Dust  or  dirt, 
nothing  else,  is  the  cause,  and  it  means  some  lack  of 
asepsis  in  the  tying  and  cutting  of  the  cord,  or  its 
after-care. 

The  first  symptom  the  nurse  may  note  is  the  general 
illness  of  the  child,  then  refusal  to  nurse,  then  stiffness 
of  the  jaws;  now  come  rigid  convulsions — the  body  may 
become  as  stiff  as  a ruler. 

Treatment  has  been  fruitless,  although  perhaps  with 
the  antitetanus  serum  there  may  be  more  hope  of  saving 
the  child.  In  hospitals  care  must  be  taken  not  to  carry 
the  infection  from  one  infant  to  another. 

Complications  Due  to  the  Use  of  Hot-water 
Bag’s.  -The  hot-water  bag  itself  should  not  be  a com- 
plication of  the  first  infancy,  but  it  not  infrequently  is  so. 
Nurses  cannot  be  too  earnestly  admonished  to  watch 
warm-water  bags  applied  to  children  and  patients  in 
general.  If  a bag  leaks  or  if  the  cover  or  the  child’s 
skin  is  moist,  the  danger  is  greater.  The  bag  should 
never  feel  hot  to  the  skin.  The  nurse  should  not  trust 
the  sensitiveness  of  the  hand,  because  the  skin  here  is 
tough  and  cannot  judge  high  temperatures.  The  bag 
should  feel  just  comfortably  hot  to  the  cheek.  It  must 
be  well  stoppered  and  perfect.  The  baby  must  be  dry. 
The  electric  pads  on  the  market  also  are  not  safe,  but 
require  watching.  Breaks  in  the  insulation  of  the  wires 
may  allow  a short  circuit  and  set  the  bed  on  fire. 


360  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

Overlying  the  Child.  When  the  infant  is  permitted 
to  lie  with  its  mother,  the  latter,  turning  in  her  sleep,  may 
strangle  it.  The  nurse  will  find  the  child  dead  in  the  bed. 
In  cases  of  illegitimacy  the  question  of  deliberate  infanti- 
cide will  come  up. 

Asphyxia  Neonatorum.  —Children  sometimes  die 
of  asphyxia  while  still  in  the  uterus,  but  more  often  they 
are  lost  through  this  accident  during  or  just  after  delivery. 
The  asphyxia  may  be  caused  by  too  early  separation  of 
the  placenta,  by  compression  of  the  umbilical  cord,  or  by 
pressure  on  the  brain.  Before  delivery,  the  physician 
knows  the  infant  is  in  danger  of  asphyxia  by  the  irregu- 
larity of  the  heart-tones  and  the  passage  of  meconium. 


Fig.  178. — The  tracheal  catheter.  This  should  never  be  boiled,  as  it  is  woven 
and  varnished.  It  is  sterilized  in  bichlorid  solution  or  formaldehyd  vapor. 


There  are  two  degrees  of  asphyxia,  called  asphyxia 
livida  and  asphyxia  pallida,  the  first  being  mild,  the  lat- 
ter, severe.  In  livid  asphyxia  the  child  is  dark  blue  and 
stiff  and  the  face  is  swollen ; in  pallid  asphyxia  the  child 
is  pale,  except  around  the  mouth,  which  is  blue,  the  body 
is  limp  as  a rag,  and  the  heart  beats  faintly  or  not  at 
all.  Unless  the  child  can  soon  be  gotten  to  respire  regu- 
larly, it  will  die. 

Treatment. — This  consists  of  removal  of  foreign  mat- 
ter from  the  air-passage,  preservation  of  the  body  heat, 
and  artificial  respiration.  The  physician  may  aspirate 
mucus,  blood,  etc.,  that  may  have  been  drawn  into  the 
windpipe,  by  means  of  a tracheal  catheter  (Fig.  178),  or 
he  may  hold  the  infant  as  in  Fig.  1 79  and  wipe  the  mucus 
from  the  back  of  the  throat.  By  compressing  the  chest 


SUNDRY  COMPLICATIONS 


36l 


the  mucus  may  be  brought  out  of  the  trachea  within 
reach  of  the  finger.  The  infant  is  then  placed  in  a hot 
bath  (1060  F.).  Some  physicians  place  the  infant  alter- 


Fig.  179. — Resuscitation,  of  an  asphyxiated  infant. 

nately  in  hot  and  cold  water — a severe  shock  to  the  little 
one,  and  a procedure  the  author  has  never  found  necessary. 
In  mild  cases  these  measures  suffice  to  bring  about 


362  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 


normal  breathing,  but  in  asphyxia  pallida  the  respiratory 
apparatus  is  paralyzed,  and  the  physician  or  nurse  must 
perform  artificial  respiration  until  the  nerve-centers  re- 
cover enough  to  carry  on  the  function. 

There  are  many  methods  of  substitute  breathing,  but 
the  nurse  may  practice  only  a few,  the  others  being  dan- 
gerous and  for  the  physician  to  employ. 

A simple  method  is  shown  in  Fig.  179.  The  child  is 
supported  by  the  feet,  with  the  forehead  resting  on  a 


Fig.  180. — Author’s  modification  of  Byrd’s  method  of  resuscitation  of  as- 
phyxiated infant.  First  motion.  Expiration.  Child  is  nearly  inverted  to 
allow  fluids  to  run  into  the  throat,  from  which  they  are  removed  by  the  finger. 

table,  so  that  the  head  is  pressed  a little  backward. 
Mucus,  blood,  etc.,  are  removed  from  the  fauces,  and 
then,  with  the  thumb  over  the  back  and  the  fingers  over 
the  front  of  the  chest,  the  nurse  makes  light  compression. 
This  forces  the  chest  together,  and,  by  suddenly  relaxing 
the  pressure,  the  elasticity  of  the  ribs  opens  the  chest 
and  air  can  be  heard  to  rush  in.  This  maneuver  is 
repeated  twenty  times  a minute. 

Another  method,  known  as  Byrd’s,  consists  in  alter- 
nately folding  and  unfolding  the  child  like  a book  (Figs. 


SUNDRY  COMPLICATIONS 


363 


180,  18 1).  Sylvester’s  method,  used  so  much  in  resus- 
citating drowned  persons,  may  also  be  employed  (Figs. 
182,  183).  It  consists  of  alternately  stretching  the  arms 
high  above  the  head  and  pressing  them  down  fast  to  the 
sides.  The  physician  may  insert  a tube  into  the  trachea 
and  blow  air  directly  into  the  lungs.  Oxygen  is  some- 
times used,  and  with  success. 


Fig.  1 81. — Author’s  modification  of  Byrd’s  method  of  resuscitation  of  as- 
phyxiated infant.  Second  motion.  Inspiration.  Child’s  head  is  raised,  and 
whole  body  strongly  extended. 

Throughout  all  these  procedures  continual  care  is  to 
be  taken  not  to  cool  the  babe  too  much.  The  skin  is 
wet,  the  child  shocked,  and  it  refrigerates  rapidly.  In 
fact,  sometimes  the  child  dies  because  of  too  violent  and 
prolonged  manipulations  intended  for  resuscitation. 
The  hot  bath,  warm  flannel  receivers,  and  the  warm- 
water  bag,  gentle  friction  with  a warmed  hand  under 
cover,  all  tend  to  keep  up  the  babe’s  temperature. 


364  DISORDERS  OF  THE  FIRST  WEEKS  OF  LIFE 

After  the  child  has  begun  to  breathe,  it  should  be 
warmly  clad,  placed  in  an  airy  room  surrounded  by 
warm-water  bottles,  or,  if  there  was  much  shock,  in  the 
incubator  for  a few  hours. 


Fig.  182. — Sylvester’s  method  of  performing  artificial  respiration.  First 
motion.  Expiration.  The  arms  are  pressed  firmly  against  the  chest.  The 
infant  is  covered  with  a warmed  towel  during  all  these  maneuvers. 


Infants  revived  from  asphyxia  occasionally  develop  a 
secondary  asphyxia  which  is  worse  than  the  first,  as 
it  is  due  to  atelectasis  pulmonum  or  hemorrhages  into 
its  brain.  The  child  is,  therefore,  to  be  carefully 


Fig.  183. — Sylvester’s  method  of  performing  artificial  respiration.  Second 
motion.  Inspiration.  The  arms  are  stretched  firmly  above  the  head. 


watched  for  signs  of  returning  cyanosis  and  for  the  char- 
acteristic grunt  or  moan.  Since  hemorrhage  may  occur 
in  the  brain,  the  nurse  will  watch  for  symptoms  of  cere- 
bral irritation,  although  treatment  of  such  accidents  is 
not  hopeful. 


CHAPTER  VI 


THE  CARE  OF  PREMATURE  INFANTS 

The  care  of  premature  infants  requires  the  highest 
kind  of  nursing  skill  and  the  greatest  self-sacrifice  and 
devotion.  The  results,  however,  are  gratifying  in  the 
extreme,  as  nearly  every  child  that  can  respire  and  digest 
food  can  be  saved.  These  children  grow  up  and  are 
strong,  so  that  there  is  no  argument  for  refusing  them 
the  necessary  care. 

There  is  a popular  notion  that  children  of  the  eighth 
month  of  pregnancy  have  less  chance  of  survival  than 
those  of  seven  months.  This  notion,  like  many  others, 
is  a popular  fallacy,  although  it  is  very  old,  dating  from 
the  time  of  Hippocrates,  who  said  that  the  weakness  of 
the  eight  months’  child  was  due  to  its  being  tired  with 
efforts  to  leave  the  uterus,  whereas  if  it  waited  until  the 
ninth  month  it  was  sufficiently  strong. 

The  longer  the  infant  remains  in  the  womb,  the 
stronger  it  becomes,  although  if  the  pregnancy  goes  too 
far  over  time,  the  child  may  die.  We  regard  as  prema- 
ture all  children  born  before  three  weeks  of  the  normal 
end  of  pregnancy.  Depending  on  the  degree  of  prema- 
turity, the  children  present  the  following  characteristics: 
They  are  small,  weighing  from  2 to  5 pounds;  the  skin  is 
red,  thin,  and  the  blood-vessels  show  through;  the  body 
is  partly  covered  with  a fuzzy  growth  of  fine  hair  called 
lanugo;  the  nose  has  little  white  comedones;  the  ears  are 
soft  and  pliable;  the  child  looks  old,  especially  after  a 

365 


366  THE  CARE  OF  PREMATURE  INFANTS 


week,  when  the  loss  of  weight  has  occurred,  and  the 
little  body  is  shriveled ; the  cry  is  weak  and  whining,  but 
most  of  the  time  the  infant  lies  in  a peculiar  stupor;  the 
temperature  has  a tendency  to  be  subnormal  and  very 
irregular;  the  bowels  are  sluggish;  the  urine  is  scanty; 
later  jaundice  is  usually  marked. 

The  initial  loss  of  weight  is  relatively  greater  in  prema- 
ture infants,  and  the  return  to  the  birth-weight  is  much 
slower,  requiring  some  twenty  to  thirty  days  (Fig. 
184).  Since  the  appetite  is  often  in  abeyance,  these 
little  mites  would  starve  to  death  unless  fed  forcedly. 
The  lungs  of  premature  infants  are  slow  to  unfold, 
remaining  in  a condition  called  atelectasis  pulmonum. 
This  is  usually  fatal,  unless  properly  relieved. 

Latterly  our  knowledge  of  premature  infants  has  in- 
creased, and  we  are  more  successful  in  rearing  them. 
To  be  successful  requires  three  things:  first,  mother’s 
milk;  second,  good  nursing;  third,  a good  incubator. 
That  heat  is  absolutely  necessary  for  premature  infants 
was  known  since  ancient  times.  In  the  Middle  Ages 
premature  infants  were  wrapped  in  the  skin  of  a sheep 
with  the  wool  on,  or  put  in  a jar  of  feathers.  Later  they 
were  enveloped  in  cotton.  Sterne,  in  the  middle  of  the 
eighteenth  century,  relates  how  the  child  of  a physician 
was  raised  by  the  “same  artifice  that  one  used  to  make 
chickens  hatch  in  Egypt.  He  put  his  son  in  an  oven, 
properly  constructed,  heated  regularly,  the  temperature 
of  which  was  regulated  by  suitable  instruments.” 
Nothing  came  of  this  suggestion. 

In  1857  Denuce  described  a double-walled  bath-tub, 
with  water  in  the  interspace,  for  the  rearing  of  feeble  in- 
fants. In  1866  Crede,  of  Leipsic,  used  an  identical  con- 
trivance, although  he  did  not  publish  it  until  1884.  In 
1880  Tarnier  had  Odile  Martin,  a poultry  raiser  of  the 
Jardin  de  Plantes,  Paris,  constructed  an  infant  incubator 


Fig.  184. — Premature  infant’s  weight  chart. 


THE  CARE  OF  PREMATURE  INFANTS  367 


on  the  plan  of  a chicken  incubator.  It  was  installed  in 
the  Maternite,  and  could  hold  several  children.  Winckel 
constructed  a permanent  bath  in  which  the  child  floated, 
thus  avoiding  the  rapid  evaporation  and  to  imitate 


Fig.  185. — Winckel’s  permanent  bath  for  premature  infants. 


more  closely  the  liquor  amnii  (Figs.  185,  186).  This 
bath  is  obsolete  now.  Some  hospitals  have  a double- 
walled  room,  properly  ventilated  and  heated  to  84°  F. 
all  the  year  round.  The  discomfort  of  the  attendants  and 


Fig.  186. — Winckel’s  permanent  bath  for  premature  infants. 


the  danger  of  spreading  infection  among  these  suscep- 
tible infants  are  the  objections  to  this  method.  The 
individual  incubator  connected  separately  with  the  out- 
side of  the  house  by  an  air-intake  pipe  is  the  best. 


368  THE  CARE  OF  PREMATURE  INFANTS 


THE  INCUBATOR  OR  COUVEUSE 

There  are  several,  made  of  wood  and  of  metal,  on  the 
market.  Some  open  at  the  top,  others  at  the  front. 
Some,  as  the  Auvard,  are  heated  by  hot-water  bottles, 
some  by  hot  air,  some,  as  the  Sharp  and  Smith,  by  hot 
water  (Fig.  187).  Most  are  heated  by  hot  water,  which 
is  by  far  the  best  method,  because  the  temperature  is 
kept  evenly.  Most  incubators  have  no  automatic  heat 
regulation,  and  with  such  the  nurse  must  carefully  watch 
the  thermometer  which  is  placed  inside,  and  provide  more 


Fig.  187. — The  Sharp  and  Smith  incubator. 


or  less  heat  as  needed.  Both  overheating  and  chilling 
are  to  be  avoided.  A few  instruments  have  automatic 
heat  regulation,  but  even  here  the  nurse  must  occasion- 
ally consult  the  thermometer  to  assure  herself  that  the 
thermostat  (or  heat  regulator)  is  working  properly. 

In  all  incubators  heated  by  steam  or  hot  water  the 
nurse  must  see  that  the  supply  of  water  does  not  run 
low.  This  endangers  the  infant  and  also  the  apparatus. 

The  ventilation  of  the  incubator  is  highly  important. 
The  writer  has  never  seen  a closed  incubator  ventilate 


THE  INCUBATOR  OR  COUVEUSE 


369 


properly  unless  it  was  connected  with  the  air  outside  the 
building.  All  incubators  of  the  box  type  require  the  lid 
to  be  left  slightly  open,  to  insure  the  infant  an  adequate 
fresh-air  supply.  This  is  especially  necessary  in  summer. 
The  air  seems  to  stagnate.  The  incubator  should  be 
raised  at  least  2 feet  from  the  floor,  and  should  be  free 
from  exposure  to  drafts,  dust,  and  chilling.  It  must  be 
lighted,  because  for  the  first  week  the  infant  requires 
close  watching. 

If  an  incubator  of  modern  type  cannot  be  obtained, 
one  can  improvise  a warm  nest  for  the  infant  by  means 
of  a large  clothes-basket  well  lined  with  blankets,  a soft 
pillow,  and  six  or  eight  hot- water  bottles.  These  are 
changed  frequently.  With  constant  attention  such  a 
makeshift  will  do  better  work  than  most  of  the  incuba- 
tors on  the  market. 

Every  city  should  be  provided  with  an  “incubator 
station.”  This  is  a plant  connected,  preferably,  with  a 
lying-in  hospital,  consisting  of  several  incubators  and 
the  necessary  specially  trained  nurses,  wet-nurses,  and 
mechanical  appurtenances.  To  these  stations  children 
could  be  brought,  even  from  great  distances,  for  that  par- 
ticular care  which  special  training  and  practice  only  are 
able  to  bestow.  The  station  of  the  Chicago  Lying-in 
Hospital  is  a model  of  this  class,  and  deserves  a short 
description  here: 

As  shown  in  Figs.  188  and  189,  the  incubators  are  of 
steel  and  glass,  and  embody  principles  of  heating  and  air 
circulation  used  in  no  others.  They  are  heated  by  a 
hot-water  pan  placed  5 inches  below  the  infant’s  bed. 
The  boiler  for  heating  the  water  in  the  pan  may  be  seen 
at  the  right  side.  The  system  is  identical  with  that  used 
in  the  hot-water  heating  of  houses.  The  heat  regu- 
lator is  above  the  boiler,  and,  once  set  at  the  desired 
temperature,  requires  no  attention.  The  child  is  handled 
24 


370  THE  CARE  OF  PREMATURE  INFANTS 

through  the  two  doors  in  front,  and  is  fed  through  the 
sliding  window  on  the  left.  On  the  left  also  is  a box 
containing  a glass  of  water.  This  is  for  moistening  the 


Fig.  1 88. — Two  of  the  incubators  of  the  system  at  the  Chicago  Lying-in  Hospital. 


air.  The  air,  fresh  from  the  sunny  outside,  is  led  by  a 
3 -inch  flue  directly  into  the  box,  passing  through  a 
cotton  filter.  The  opening  from  the  box  into  the  heating 


THE  INC UBA TOR  OR  COUVEUSE 


371 


Fig.  189. — Diagrammatic  section  of  incubator  system  in  Chicago  Lying-in 
Hospital:  a.  Pipe  bringing  air  from  outside;  b,  damper;  c,  cotton  filter;  e,  glass 
of  water  in  moisture-box;/,  screen  to  distribute  air  evenly  under  warming-pan; 
g,  water-pan;  h,  flue  conducting  air  into  bed-chamber;  j,  bed;  k,  draft  plate  to 
lead  air  out  of  bed-chamber  into  flue  l;  l,  escape  flue;  m,  chimney;  n,  anemoscope; 
0,  ethyl-chlorid  disks;  p,  lever;  q,  cover  of  air-flue  over  heater;  r,  hot- water 
boiler;  v,  gas-burner;  x,  air- vent  to  hot- water  system;  y,  exit  flue  through  ceiling; 
z,  filling  cup  for  the  hot-water  heating  system.  The  dotted  line  shows  the 
course  of  the  air  through  the  instrument. 


chamber  of  the  incubator  is  closed  by  a sliding  damper, 
by  which  the  amount  of  air  admitted  to  the  apparatus  is 
regulated.  The  air  is  heated  by  passing  around  a large 


372 


THE  CARE  OF  PREMATURE  INFANTS 


pan  of  water  (connected  by  pipes  with  the  water  boiler 
on  the  outside),  and,  after  circulating  around  the  infant, 
is  automatically  removed  through  a flue  on  the  top  of  the 
box.  A little  wheel  in  this  flue  (an  anemoscope)  indi- 
cates the  current  of  air.  The  child  lies  in  a basket  sus- 


Fig.  190. — Incubator  ambulance  open,  showing  electric  light,  thermometer, 
infant’s  basket  with  eiderdown  flannel  mattress,  and  coverlet. 


pended  over  the  hot-water  pan;  the  mattress  on  which  it 
lies  is  of  eiderdown. 

A delicate  thermometer  is  fastened  near  the  side  win- 
dow, so  that  it  may  be  easily  read,  and  a hygrometer,  to 
indicate  the  degree  of  moisture,  hangs  in  the  back. 

The  room  in  which  the  incubators  are  installed  has  also 


THE  INCUBATOR  OR  COUVEUSE 


373 


a natural  ventilation  through  the  ceiling  to  a space  under 
the  eaves,  which  is  likewise  ventilated.  The  schematic 
drawing  will  show  the  tortuous  current  of  air;  the  nurse 
may  follow  the  dotted  line  in  its  windings  from  below  the 
floor,  through  the  apparatus,  and  out  through  the  ceiling. 
This  is  an  ideal  arrangement,  as  it  provides  a certainty 
of  fresh,  filtered,  moistened  air,  and  even  in  stormy 
weather  precludes  a draft  through  the  incubator. 

Many  children  have  to  be  brought  from  distances, 
sometimes  of  many  miles,  and  for  such  transporta- 


Fig.  iqi . — Incubator  ambulance  closed,  ready  for  transportation  of  infant. 
During  transit  the  child  is  closely  observed  through  a window  in  the  top. 


tion  an  ambulance  incubator  is  provided  (Figs.  190,  191). 
This  is  a perfect  incubator  in  miniature,  with  a circu- 
lating hot-water  system  heated  from  the  outside  by  an 
alcohol  lamp,  well  ventilated,  and  lighted  by  electricity. 
It  is  21  inches  long,  11  inches  wide,  and  n inches  high, 
and  can  be  easily  carried  by  one  person. 

Care  of  the  Incubator.  The  temperature  should, 
as  a general  rule,  be  kept  at  about  87°  F.  It  may  fluctu- 
ate from  86°  to  910  F.  without  being  dangerous.  If  the 
infant  is  strong  or  less  premature,  or  if  it  sweats  too 


374 


THE  CARE  OF  PREMATURE  INFANTS 


much  at  this  temperature,  the  regulator  should  be  set 
at  86°  F.  or  even  84°  F.  If  the  child  is  very  premature 
or  if  its  temperature  persists  in  remaining  low,  the  in- 
cubator must  be  warmer,  being  set  at  910  or  even  930  F. 
This,  however,  is  seldom  necessary  for  any  length  of  time 
— two  or  three  days  at  most,  when  a temperature  of  87° 
F.  is  more  desirable.  With  a little  practice  the  nurse 
gets  to  know  what  degree  of  heat  is  best  suited  to  the 
particular  infant.  As  the  child  grows  older  the  tempera- 
ture of  the  apparatus  is  maintained  at  84°  or  8o°  F.,  and 
then  the  infant  is  placed  inside  only  at  night,  being  put 
in  a warm  basket  during  the  day. 

With  incubators  without  automatic  heat  regulation  the 
nurse  must  consult  the  thermometer  placed  alongside 
the  child,  and  increase  or  decrease  the  heat  by  the  means 
provided  in  the  particular  apparatus.  With  a little  ex- 
perience the  nurse  can  judge  by  putting  her  hand  inside 
the  incubator  whether  the  air  is  of  the  right  temperature, 
but  this  must  not  be  relied  on. 

The  moisture  is  important.  In  incubators  of  the  style 
last  described  this  is  provided  for  by  hanging  a piece  of 
gauze  in  the  water-glass  of  the  moisture  box  at  the  left. 
Should  the  hygrometer  or,  what  is  just  as  reliable,  the 
dry  mouth  and  lips  of  the  babe  show  that  moisture  is 
needed,  this  may  be  easily  accomplished  by  placing  a 
small  flat  pan  of  water  under  the  bed  on  the  warming- 
pan.  In  incubators  of  the  Auvard  pattern  the  moisture 
is  provided  by  a sponge  hung  near  the  head  of  the  in- 
fant. This  sponge  must  be  wet  frequently  and  sterilized 
daily,  as  it  is  not  a clean  thing.  In  summer  less  moisture 
is  needed  than  in  winter. 

The  hot-water  system  of  the  large  steel  incubators  re- 
quires little  attention.  The  filling  is  done  through  the 
cup  on  the  right  side,  and  the  system  must  be  filled  and 
water  stand  in  the  cup  before  the  gas-burner  is  lighted. 


THE  INCUBATOR  OR  COUVEUSE 


375 


Every  day  a little  water  is  supplied  to  replace  that  lost 
by  evaporation. 

In  the  old-fashioned  incubators  or  in  improvised  bas- 
kets the  hot- water  bottles  must  be  frequently  changed. 
In  those  with  steam  boilers  great  care  must  be  taken 
that  the  kettle  does  not  boil  dry. 

The  Ventilation. — If  the  incubator  is  provided  with 
a flue  and  wheel,  or  anemoscope,  the  nurse  can  easily  see 
that  air  is  passing  through  the  apparatus  by  the  motion  of 
the  wheel.  This  wheel  must  be  delicate  and  sensitive,  or 
it  will  fail  to  show  the  circulation  of  air.  The  nurse 
must  see  that  the  bearings  of  the  wheel  are  free  from 
dust  and  slightly  oiled.  Great  care  is  necessary  in  hand- 
ling it  because  of  its  delicacy.  If  there  is  no  indicator 
of  this  kind,  and  in  box  incubators,  it  is  safest  to  leave  the 
sliding  cover  or  door  open  a trifle,  and  protected  from 
drafts  by  hanging  a towel  over  it.  This  is  necessary  in 
summer  in  all  apparatus  not  connected  with  the  outside 
air.  In  addition,  the  ventilator  openings  provided  in  the 
incubator  are  left  free.  In  winter  or  in  very  windy  local- 
ities those  incubators  connected  directly  with  the  out- 
side air  need  a little  watching.  While  experience  has 
shown  that  they  can  accommodate  themselves  to  a 
change  from  450  above  to  8°  below  zero,  and  also  func- 
tionate in  a gale  blowing  60  miles  an  hour,  still  the  little 
life  inside  is  so  delicate  and  precious  that  one  must  be 
assured  the  apparatus  is  working  properly.  In  winter 
the  damper  in  the  air-flue  is  kept  almost  closed;  in  sum- 
mer, wide  open. 

The  Bed. — The  incubator  bed  should  be  of  eiderdown. 
No  rubber  sheet  is  used.  No  pillow  is  needed.  Some- 
times it  may  be  necessary  to  lower  the  infant’s  head, 
which  is  done  by  raising  the  foot  of  the  basket.  Cotton 
has  been  found  objectionable  as  a mattress  for  the  tiny 


376  THE  CARE  OE  PREMATURE  INFANTS 


babies;  it  is  used  for  the  larger  ones  and  after  the  little 
ones  have  developed. 

The  Dress.-  This  should  be  of  the  finest  wool  flannel 
obtainable,  and  made  as  simple  as  possible.  The  idea  of 
wrapping  the  infants  in  cotton  and  oil  is  a popular  fallacy 
and  costs  lives.  As  soon  as  a premature  infant  is  bom,  it 


should  be  wrapped  in  warm  wool  flannel  and  placed  in 
the  incubator.  If  no  incubator  is  at  hand,  until  proper 
provision  can  be  made  the  child,  wrapped  in  a warm 
woolen  blanket,  is  surrounded  by  warm-water  bottles 
and  kept  in  a very  warm  room.  The  nurse  will  note 


THE  INCUBATOR  OR  COUVEUSE 


3 77 


how  the  necessity  of  heat  is  emphasized.  The  Chicago 
Lying-in  Hospital  has  received  60  or  more  infants, 
completely  refrigerated,  even  though  oiled  and  wrapped 
in  cotton. 

A simple  bag,  34  inches  long  and  20  inches  wide  at 
the  bottom,  stitched  around  the  neck,  without  sleeves, 
has  been  found  the  best  (Fig.  192).  It  is  open  at  the 
bottom,  so  that  the  infant  may  be  “changed”  without 
trouble,  and  long  enough  to  double  over  and  make  a sort 


Fig.  193. — Incubator  infant  as  it  lies  in  the  apparatus,  showing  the  dress 
folded  up  over  the  body,  making  a blanket,  and  the  shawl  over  the  head  and 
shoulders. 


of  cover  reaching  to  the  shoulders.  The  child  is  covered 
by  a light,  wool-flannel  blanket  which  makes  a sort  of 
hood  over  the  head  (Fig.  193) ; the  abdominal  binder  is  of 
wool,  the  diaper  alone  being  of  cotton  material. 

After  the  child  is  removed  from  the  incubator  it  natur- 
ally requires  heavier  clothing. 

Warm  Feet.  -Even  in  the  best  incubators  the  child’s 
feet  may  be  cold;  this  is  due  to  poor  circulation.  A 
warm-water  bag  should  be  laid  under  the  feet,  carefully 


378  THE  CARE  OF  PREMATURE  INFANTS 


protected  so  that  it  shall  not  burn.  The  temperature  of 
the  infant,  taken  by  the  rectum,  may  be  elevated  by  this 
warm-water  bag,  a fact  to  be  borne  in  mind  in  reporting 
or  recording  a fever. 

The  Diet. — Without  question,  mother’s  milk  is  the 
food  for  premature  infants,  and  should  be  obtained  at 
any  expense  of  money  and  effort.  It  must  come  from  a 
healthy  woman  whose  own  baby  is  thriving.  For  this 
reason  an  incubator  station  is  better  connected  with  the 
lying-in  hospital  or  it  must  have  a staff  of  wet-nurses. 
Feeding  must  begin  a few  hours  after  birth  to  avoid 
exhaustion  and  to  combat  the  great  initial  weight-loss. 

For  the  smallest  infants  from  5 to  20  drops  of  a two- 
thirds  mother’s  tnilk  in  water  are  given  every  thirty 
minutes  with  a medicine-dropper.  If  the  child  retains 
this,  the  amount  is  increased  to  30  or  40  drops.  After 
from  twenty-four  to  thirty-six  hours  the  intervals  are 
lengthened  to  an  hour,  and  later  to  two  hours. 


Diet  Table  Used  at  the  Chicago  Lying-in  Hospital 

For  Infants  Weighing  Less  than  J Pounds 
1st  day,  every  30  minutes,  15  drops:  Water  1 part,  milk  2 parts. 

2d  “ “ hour,  30  “ “ 1 “ 2 “ 

3d  “ “ “ 40  “ “ 1 “ “ 2 “ 

4th  “ “ 1 -V  hours,  1 dram:  “ 1 “ “2  “ 

5th  “ “ i\  “ 1 “ Pure  mother’s  milk. 

6th  “ “ 2 “ * i|  drams:  “ “ 

7th  “ “ 2 “ if 


For  Infants  Weighing  Less  than  1800  Grams  (j  lbs.  12  ozs .) 


Total  quantity.  Every  hour  about 


1 st  day 

63  gm. 

( 2 

oz.  \ dr.) 

45 

drops. 

2d  “ 

127  “ 

( 4 

oz.  \ dr.) 

66 

3d  “ 

151  “ 

( 5 

oz.) 

4 

drams. 

4th  “ 

200  “ 

( 63 

! OZ.) 

2 

U 

5th  “ 

224  “ 

( 7 

oz.  2 dr.) 

2 

“ 15ml 

6 th  “ 

230  “ 

( 7 

oz.  4 dr.) 

2\ 

u 

7th  “ 

263  “ 

( 8| 

! OZ.) 

2 

“ 45HH 

8th  “ 

281  “ 

( 9 

oz.) 

3 

U 

9 th  “ 

303  “ 

(10 

oz.) 

• • • 3§ 

66 

THE  INCUBATOR  OR  COUVEUSE 


379 


For  Infants  Weighing  from  1800  to  2200  Grams  (3  lbs.  12  ozs. -4  lbs.  9 ozs.) 


Total  quantity. 

1st  day  120  gm.  ( 4 oz.) .... 

2d  “ 173  “ (sioz.). ... 

3d  “ 247  “ (8oz.) 

4th  “ 281  “ ( 9 oz.) 

5th  “ 312  “ (10  oz.) 

6th  “ 347  “ (11  oz.  2 dr.) 

7th  “ 364  “ (11  oz.  7 dr.) 

8th  “ 393  “ (12  oz.  5 dr.) 

9th  “ 404  “ (13  oz.) 


Every  hour  about 
75  drops. 

2j  drams. 

2 i “ 

3i  “ 


4 

4i 

4\ 


For  Infants  Weighing  from  2200  to  2300  Grams  {4  lbs.  9 ozs. -5  lbs.  4 ozs.) 


Total  quantity 

1st  day  153  gm.  ( 5 oz.) 

2d  “ 266  “ ( 8 oz.  5 dr.) 

3d  “ 299  “ (10  oz.) 

4th  “ 341  “ (n  oz.) 

5th  “ 365  “ (n  oz.  7 dr.) 

6th  “ 390  “ (12  oz.  5 dr.) 

7th  “ 400  “ (13  oz.) 

8th  “ 413  “ (13  oz.  3 dr.) 

9th  “ 418  “ (13  oz.  4 dr.) 


Every  hour  about 


1 1 drams. 

3 

3h  “ 

3i  “ 

4 
4* 

4\  “ 

4f  “ 

5 


One  cannot  follow  this  table  exactly,  some  infants  re- 
quiring less,  others  more,  than  herein  stated;  some  in- 
fants require  diluted  milk  for  weeks.  A small  child  that 
is  several  weeks  old  requires  more  than  a larger  infant  in 
the  first  days.  Occasionally  a 3 -pound  baby  will  drink 
1 ounce  of  milk  every  two  hours.  As  a general  rule 
the  child  is  allowed  as  much  as  it  can  be  induced  to 
swallow,  and  the  appetite  varies  day  and  hour.  One 
must  not  overfeed,  because  of  the  danger  of  indigestion 
and  regurgitation.  The  former  invites  intestinal  ca- 
tarrh, while  the  latter  may  lead  to  choking  and  asphyxia- 
tion. On  the  other  hand,  one  must  give  sufficient 
nourishment,  because  the  spark  of  life  is  faint  and  the 
child  cannot  express  hunger.  Feeding  must,  therefore, 
begin  soon  after  birth,  and  be  carefully  and  consistently 
practised.  If  the  infant  does  not  get  enough  food,  it 
will  lose  weight,  it  will  lie  in  a peculiar  stuporous  condi- 


380  THE  CARE  OF  PREMATURE  INFANTS 


tion,  and  will  be  subject  to  attacks  of  fainting,  some- 
times with  marked  cyanosis. 

The  amount  of  each  feeding  must  be  recorded,  and  if 
the  infant  nurses  at  the  breast,  it  must  be  weighed  on  a 
delicate  scale  before  and  after  nursing,  the  difference 
representing  the  amount  obtained.  The  total  in  twenty- 
four  hours  gives  the  amount  ingested  by  the  infant.  It 


Fig.  194. — The  nursing  bottle  for  prema-  Fig.  T95. — The  feeding-dropper, 
ture  infants.  Capacity,  1 ounce. 

should  be  equivalent  to  about  one-fifth  of  the  child’s 
weight.  Thus  a child  weighing  3 pounds  should  be 
fed  about  9 ounces  of  milk  a day.  If  the  child  shows 
any  symptoms  of  indigestion,  a little  peptic  salt  is  given 
with  each  feeding. 

Method  of  Feeding. — If  the  infant  can  suck  and 
swallow,  the  milk  is  given  by  means  of  a small  vial  and 


THE  INCUBATOR  OR  COUVEUSE  38 1 

a tiny  nipple  (Fig.  194).  If  the  child  can  swallow  but 
not  suck,  the  milk  is  dropped  into  the  throat  with  a 
feeding-dropper  (Fig.  195).  The  breast-pump  that 
draws  the  milk,  the  bottle,  the  dropper,  the  nipples,  etc., 


Fig.  196. — The  practice  of  gavage. 

must  always  be  sterile  to  avoid  infecting  the  intestinal 
tract. 

Should  the  child  neither  suck  nor  swallow,  it  must  be 
fed  by  means  of  a method  known  as  gavage,  introduced 
by  Tarnier,  of  Paris  (Fig.  196).  This  consists  simply  of 


382  THE  CARE  OF  PREMATURE  INFANTS 


feeding  by  means  of  a stomach- tube.  The  tube  used  is  a 
soft-rubber  catheter,  size  8,  American  scale,  for  the  tiny 
babes,  and  No.  10  for  the  larger  ones.  It  is  attached  to 

a small  funnel  or  the  glass 
part  of  a nipple-shield. 
When  the  proper  amount 
of  milk  is  obtained,  which 
is  done  by  means  of  a 
breast-pump  (see  Fig.  77), 
it  is  diluted  and  warmed, 
and  the  tube,  etc.,  steril- 
ized. The  infant  is  placed 
on  the  lap  with  the  face 
upward  and  a little  to  one 
side  (Fig.  196).  The  tube 
is  filled  with  milk,  clamped 
with  the  fingers,  passed 
into  the  throat,  and  quickly 
into  the  stomach.  A depth 
of  4 inches  is  usually  right. 
The  child  swallows  the 
tube  sometimes  with  avid- 
ity. Then  the  measured 
quantity  of  milk  is  slowly 
poured  in,  taking  care  that 
air  is  not  permitted  to 
enter.  Then  the  tube  is 
withdrawn  with  a rather 
quick  motion,  the  child 
is  held  quiet  for  a few 
moments,  after  which  it  is 
carefully  replaced  in  the 
incubator  on  its  side.  The  child  must  be  watched  for  a 
few  minutes  to  see  that  the  milk  does  not  regurgitate 
and  strangle  it. 


Fig.  197. — The  teterelle,  showing 
front  and  side  view.  Above  and  to 
the  left  a glass  bulb  to  collect  saliva 
that  might  flow  down  the  tube. 


THE  INCUBATOR  OR  COUVEUSE 


383 


Overfeeding  is  very  prone  to  occur  with  gavage, 
therefore  one  must  refer  to  the  table  herein  given,  and 
watch  the  infant  for  signs  of  distress,  as  abdominal 


Fig.  198. — The  teterelle  in  use. 


distention,  vomiting,  indigestion,  etc.  Tiny  infants 
are  fed  in  the  incubator  through  the  side  window  or  by 
partly  removing  the  cover  of  those  constructed  on  the 


384  THE  CARE  OF  PRE MATURE  INFANTS 


box  pattern,  but  after  the  child  is  strong  enough  it  is  fed 
on  the  lap  of  the  nurse,  in  a warm  room,  and  protected 
from  drafts.  For  gavage  one  must  remove  the  infant 
from  the  couveuse. 

As  soon  as  the  babe  can  be  put  directly  to  the  breast, 
this  should  be  done,  as  nothing  can  match  the  life-giving 
fountain.  If  the  nipple  is  too  large,  or  if  the  milk  does 
not  flow  readily,  a teterelle  (Fig.  197)  may  be  used.  The 
nurse  compresses  the  tube  leading  from  the  bulb  with  the 
fingers,  the  mother  draws  the  milk  into  the  bulb,  and 
then  the  nurse  allows  it  to  flow  into  the  child’s  mouth 
(Fig.  198).  A pump  may  be  used  instead. 

One  should  see  that  the  infant  has  sufficient  water. 
Since  the  interior  of  the  incubator  is  warm  and  the  skin  is 
thin,  evaporation  is  rapid,  and,  therefore,  the  little  body 
dries  out. 

If  mother’s  milk  is  positively  unobtainable,  we  are 
forced  to  rely  on  substitute  feeding. 

The  Bath.  -Premature  infants  should  be  handled  as 
little  as  possible,  because  it  is  depressing  to  them.  A 
bath  such  as  is  usually  given  to  infants  may  throw  them 
into  collapse.  The  practice  of  smearing  the  infant  with 
vaselin  or  sweet  oil  is  bad,  as  it  refrigerates  the  little 
body.  The  skin  must  be  kept  clean  and  the  pores  open 
or  the  infant  will  not  thrive.  As  soon  as  the  child  is 
born  it  is  covered  warmly,  and,  in  a hot  room,  the  whole 
body  is  anointed  with  warm  benzoinated  lard.  This  is 
carefully  and  quickly  wiped  off,  under  cover,  with  a hot 
towel.  The  child  is  immediately  placed  in  the  incubator. 
If  the  infant  is  very  weak  the  first  dressing  is  postponed 
several  hours  or  until  it  has  recovered  from  the  shock  of 
birth  and  the  unavoidable  exposure  afterward. 

Daily  for  the  first  week  the  whole  body  is  anointed 
with  finest  benzoinated  lard,  an  animal  fat  that  sinks  into 
the  skin  and  furnishes  a small  amount  of  food.  The  face 


THE  INC UBA  TOR  OR  COUVEUSE  385 

and  buttocks  are  occasionally  washed  with  warm  water. 
When  the  infant  is  sturdier,  it  is  given  what  is  known  as 
a “dip”  every  other  day.  This  is  a gentle  immersion 
into  water  at  103°  F.  for  not  over  thirty  seconds.  Then 
the  little  body  is  quickly  lifted  into  a warm  towel  and 
dried.  After  this  the  whole  body  is  anointed  with  the 
benzoinated  lard.  The  bath  as  usually  given  is  not 
employed  until  the  child  is  quite  vigorous. 

The  Care  of  the  Byes,  Nose,  Mouth,  etc.— The 
eyes  are  not  given  any  attention  except  ordinary  cleanli- 
ness, and  the  same  may  be  said  of  the  nose,  ears,  and 
mouth.  Extraordinary  care  must  be  used  not  to  injure 
or  abrade  the  tender  mucous  membranes,  as  the  infant  is 
very  susceptible  to  infection,  which  may  easily  gain  en- 
trance in  this  manner.  Each  morning  the  mouth  may 
be  washed  with  boric  acid  solution,  but  this  is  not  needed 
if  the  tongue  is  clean.  In  girls  the  vulva  must  be  handled 
with  extreme  delicacy  and  care  be  taken  not  to  infect  it. 
The  buttocks  are  so  tender  that  the  skin  cracks  and  in- 
flames easily,  especially  if  the  bowel  movements,  from 
indigestion  or  enteritis,  are  sharp  and  irritating.  In  such 
cases  no  water  should  be  used,  and  the  treatment  de- 
scribed on  page  343  should  be  minutely  carried  out. 

In  boys  the  diaper  should  be  applied  loosely,  thus 
avoiding  compression  of  the  delicate  external  organs. 
The  meatus  urinarius  should  be  inspected  frequently,  as 
a tiny  bit  of  dried  secretion  might  stop  the  flow  of  urine. 

The  infant  must  not  lie  long  after  urination  or  bowel 
movement  before  changing,  first,  because  the  discharges 
decompose  quickly  in  the  warm  incubator  and  befoul  the 
air  in  it;  second,  because  the  skin  around  the  nates  will 
become  inflamed,  and  third,  because  it  may  lead  to  in- 
fection of  the  child.  The  change  must  be  made  quickly 
and  gently,  with  the  smallest  amount  of  exposure,  and 
the  child  returned  to  the  incubator  without  delay.  Some 
25 


386  THE  CARE  OF  PREMATURE  INFANTS 

incubators  are  arranged  to  allow  this  attention  without 
removal  of  the  child. 

General  Care.  -Every  day  during  the  anointing  the 
infant  is  given  a general  massage.  This  comprises  gentle 
rubbing  of  the  skin,  kneading  of  the  muscles  of  the  ex- 
tremities, and  bending  of  the  joints.  That  this  must  be 
extremely  gentle  and  tentative  at  the  start  and  more 
vigorous  as  the  child  grows  stronger  is  not  necessary  to 
say.  If  the  child  is  very  premature,  these  attentions  are 
given  every  other  day.  They  are  not  omitted,  because 
the  infant  needs  some  stimulation  to  bring  it  out  of  the 
torpid  state  in  which  it  usually  lies,  and  which  disposes 
it  to  stagnation  of  the  blood  in  the  extremities  and  the 
lungs.  The  child  should  lie  alternately  on  the  two  sides 
for  the  same  reason.  The  temperature  is  taken  by  the 
rectum  morning  and  evening,  and  every  four  hours  if 
there  is  fever.  Every  other  day  the  infant  is  weighed 
naked,  and  care  should  be  taken  that  the  little  body  is 
not  chilled.  For  the  weighing  the  babe  is  wrapped  in  a 
hot  diaper.  A record  is  kept  of  all  these  things. 

Removal  from  the  Incubator. — This  depends  on 
the  age  of  the  child  and  the  rate  of  growth.  As  a general 
rule,  when  the  temperature  remains  normal  for  days, 
when  the  child  is  about  4J  to  4J  pounds  in  weight,  we 
remove  it  to  its  cradle.  This  varies,  of  course;  so  the 
length  of  stay  is  from  five  days  to  six  weeks.  There 
should  be  no  haste  in  removing  the  child,  as  it  will  thrive 
better  in  the  apparatus,  having  less  to  contend  with. 
Operative  cases  are  removed  when  they  have  recovered 
from  the  shock  of  the  delivery.  Some  infants,  even 
though  small,  are  uncomfortable  in  the  incubator,  and 
sweat  profusely,  cry,  and  are  fretful.  These  cases, 
which  are  rare,  do  better  in  a warm  crib.  Often  these 
symptoms  denote  fever  due  to  some  other  cause,  which, 
being  relieved,  the  infant  is  comfortable  again  in  the 


DISEASES  OF  PREMATURE  INFANTS  387 


incubator.  The  change  from  the  incubator  to  the  crib 
must  be  made  gradually.  If  the  incubator  is  of  the  box 
pattern,  the  lid  is  removed  for  part  of  the  day.  If  the 
couveuse  has  automatic  heat  regulation,  this  must  not  be 
done,  as  opening  the  doors  disturbs  the  thermostat; 
here  the  infant  is  gradually  accustomed  to  being  outside 
by  being  kept  in  a warm  crib  or  on  the  nurse’s  lap  for 
longer  and  longer  periods.  After  a while  it  is  placed  in 
the  incubator  only  at  night,  and  if  it  bears  this  treatment 
well,  it  is  left  in  the  crib  entirely. 

THE  PARTICULAR  DISEASES  OF  PREMATURE  INFANTS 

These  children  may  have  all  the  affections  of  full- 
term  newborn  infants.  These  illnesses  are  very  severe, 
however,  and  the  premature  infant  is  subject  to  certain 
particular  conditions. 

After  atelectasis,  sepsis  carries  away  most  of  these 
mites  of  humanity,  and  the  nurse’s  main  function  is  to 
guard  against  it  at  all  points  of  entry.  The  entry  is 
through  the  body  orifices — mouth,  nose,  navel,  especially 
the  last — and  from  the  gastro-intestinal  tract  and  lungs. 
Infections  of  the  navel  are  rare  since  the  antiseptic  treat- 
ment of  the  stump  is  practised.  Infection  through  the 
lungs  is  not  uncommon,  but  is  hard  to  diagnose,  as  the 
symptoms  of  pneumonia  are  obscure.  Fever  is  often 
absent  and  there  is  no  cough.  A fatal  epidemic  of  bron- 
chitis was  started  in  an  incubator  nursery  in  Paris  from 
one  of  the  wet-nurses  who  had  caught  an  ordinary  “cold 
in  the  head.”  Forty  children  succumbed.  Infection  of 
the  gastro-intestinal  tract  is  easy  to  find,  since  there  is 
usually  diarrhea,  with  sharp,  irritating,  green,  foamy,  or 
offensive  stools,  and  there  are  often  fever,  tympanites, 
and  vomiting. 

The  infection  of  the  digestive  tract  may  come  from  the 
mouth,  from  the  air  in  the  incubator,  from  the  food  given, 


388  THE  CARE  OF  PREMATURE  INFANTS 

from  the  fingers  of  the  attendant,  and  from  the  bottles, 
nipples,  etc.,  used.  The  importance,  therefore,  of  abso- 
lute and  constant  cleanliness  needs  no  emphasis. 

The  child  sometimes  suffers  from  simple  indigestion. 
This  is  nearly  always  the  case  if  bottle-feeding  is  neces- 
sary. Even  with  mother’s  milk  it  may  occur,  being  due 
to  insufficient  digestive  power  of  the  tract.  The  little 
organs  are  not  sufficiently  developed.  The  symptoms 
of  indigestion  are  vomiting,  loose  bowels,  with  curds,  but 
with  less  evidence  of  fermentation  in  the  stools,  and  pro- 
gressive loss  of  weight.  In  treating  these  cases  one 
must  be  sure  that  the  infant  is  not  being  overfed.  A 
small  feeding  is  given  several  times  to  see  if  the  stomach 
will  tolerate  it.  The  milk  must  be  properly  diluted. 
The  simple  addition  of  “peptic  salt”  to  the  milk  will 
often  correct  the  condition.  Peptic  salt  is  made  by  mix- 
ing i part  of  finest  table-salt  with  9 parts  of  best  scale 
pepsin : } grain  is  given  with  each  feeding. 

Thrush  or  sprue  is  commoner  in  premature  babies 
than  in  others.  It  is  due  to  uncleanliness  and  is  pre- 
ventable. The  treatment  recommended  on  page  333 
is  practised,  but  the  nurse  uses  greater  gentleness  not  to 
injure  the  delicate  mucous  membrane  of  the  mouth. 

Nasal  Infection.  —An  affection  which  has  been  ob- 
served not  infrequently  at  the  incubator  station  of  the 
Maternite  in  Paris,  but  with  which  we  have  had  no  ex- 
perience, is  an  ulcerative  rhinopharyngitis  due  to  decom- 
position of  food  which  the  baby  regurgitates  into  the 
nares.  Profuse  discharge  from  the  nose,  soon  becoming 
purulent,  ulceration  of  the  mucous  membrane  even  to 
the  bone,  with  the  development  of  “saddle-nose”  similar 
to  that  of  syphilis,  are  reported.  Sometimes  this  infec- 
tion causes  a bronchopneumonia  and  general  sepsis. 
The  treatment  is  one  of  local  cleanliness  and  antisepsis, 
which,  however,  is  not  easy  to  practice. 


DISEASES  OF  PREMATURE  INFANTS  389 

Cyanosis.  —A  frequent  condition  is  what  we  call 
“cyanotic  attacks”  or  “blue  spells.”  The  infant  sud- 
denly ceases  to  breathe,  turns  blue,  and  may  die  unless 
immediate  action  is  taken.  Sometimes,  however,  the 
attack  passes  over  and  the  infant  regains  its  color,  but 
is  apparently  weaker.  These  blue  spells  are  due  to  two 
causes,  which  are  directly  opposite  in  their  nature;  there- 
fore it  is  difficult  to  treat  the  condition.  First,  they  are 
the  result  of  weakness.  Dr.  O.  W.  Holmes  says,  “The 
little  waif  is  too  tired  to  pull  at  the  twenty-four  oars  of 
respiration.”  The  babe  simply  forgets  to  breathe.  The 
treatment  of  such  a case  is  first  to  relieve  the  collapse  by 
artificial  respiration,  a hot  bath,  and  stimulation  with  a 
little  coffee,  a drop  of  whisky,  or  oxygen.  If  the  nose 
of  the  child  is  stopped  up  sufficient  obstruction  may 
result  as  to  cause  death. 

Since  the  cause  of  the  cyanotic  attacks  is  exhaustion, 
it  is  important  that  the  infant  receive  sufficient  food  and 
that  it  be  assimilated.  The  feeding  must  begin  right 
after  birth;  food  should  be  given  in  small  quantities,  and 
then  in  increasing  amounts  as  the  stomach  will  tolerate  it. 

The  other  causes  of  the  cyanotic  attacks  are  overfeed- 
ing and  choking.  If  the  stomach  is  overdistended  it 
interferes  with  the  heart’s  action.  Regurgitation  of  food 
may  occur,  when  small  particles  may  be  caught  in  the 
trachea  and  strangle  the  infant. 

To  cure  this  condition  it  is  simply  necessary  to  recog- 
nize the  cause.  To  prevent  the  child  from  choking  the 
nurse  must  watch  it  very  carefully  until  its  actions  are 
well  known,  and  it  must  be  laid  gently  on  its  right  side 
after  the  feeding.  The  child  must  not  be  left  alone  for  a 
minute.  In  these  cases  the  advantages  of  a modern  in- 
cubator are  apparent,  as  one  may  keep  the  infant  under 
constant  observation. 

Should  the  child  be  found  choking,  the  nurse  must  at 


390 


THE  CARE  OF  PREMATURE  INFANTS 


once  hold  it  up  by  the  legs,  and  with  the  little  finger, 
protected  by  gauze  or  a soft  towel,  seek  to  remove  the 
obstruction  from  the  throat.  If  this  is  not  successful, 
the  chest  should  be  squeezed  from  before  backward,  in 
the  manner  illustrated  in  the  section  devoted  to  instruc- 
tion for  resuscitating  asphyxiated  babies.  As  a rule, 
these  means  suffice,  but  if  they  do  not,  the  tracheal 
catheter  must  be  employed  to  free  the  air-passages  of 
obstruction.  Needless  to  add,  the  accident  is  often  fatal, 
owing  to  the  delay  and  difficulty  in  dislodging  particles 
that  have  once  gained  access  into  the  lungs. 

The  most  fatal  complication  of  premature  infants  is 
atelectasis  pulmonum.  This  means  that  the  lungs 
of  the  child  have  not  unfolded;  the  air,  therefore,  cannot 
get  into  them,  and  the  child  nearly  always  dies  of  more 
or  less  rapid  asphyxia. 

Infants  whose  lungs  have  not  unfolded  do  not  be- 
come red  or  pink,  but  retain  a blue  color.  They  are 
often  called  “blue  babies,”  although  this  term  should  be 
reserved  for  infants  born  with  heart  disease.  The  ate- 
lectatic baby  does  not  cry  with  vigor,  but  whines,  and 
each  expiration  is  attended  by  a grunt  or  a light  groan. 
It  has  cyanotic  attacks.  Unless  the  child  can  be  made  to 
cry  vigorously  and  naturally  and  the  healthy  pink  or  red 
be  brought  back  to  the  skin,  it  will  almost  inevitably  die. 
Gradually  it  becomes  unconscious,  and  dies  in  spite  of 
every  attempt  to  restore  the  natural  breathing. 

The  means  employed  to  cure  the  condition  are  the  hot 
bath,  getting  the  infant  to  cry  by  spankings  and  rubbings 
or  electricity,  artificial  respiration,  even  forcible  attempts 
to  inflate  the  lungs  with  a catheter  in  the  trachea. 

Convulsions  in  incubator  babies  are  due  to  asphyxia 
or  to  indigestion,  with  toxemia,  sepsis,  and  the  causes  act- 
ing with  full- term  children.  (See  p.  358  for  details  of 
treatment.) 


DISEASES  OF  PREMATURE  INFANTS 


39 


In  conclusion,  a few  words  about  the  desirability  of 
saving  these  weakling  additions  to  society,  Mothers 
often  ask  if  the  children  will  grow  up  to  be  vigorous  and 
strong,  and  the  question  may  be  answered  in  the  affirma- 
tive. Many  of  the  children  nursed  in  the  incubator 
system  at  the  Chicago  Lying-in  Hospital  are  being  kept 
under  observation,  and  are  thriving.  Older  statistics  tell 
of  the  successful  rearing  of  these  undeveloped  children, 
and,  to  emphasize  all,  one  may  recall  that  Victor  Hugo 
was  a premature  child,  and  was,  in  his  own  words, 
“colorless,  sightless,  voiceless,  and  so  poor  a weakling 
that  all  despaired  of  him  save  his  mother.” 


CHAPTER  VII 


INFANT  FEEDING1 

Mothers’  milk,  first  and  always,  is  the  proper  food  for 
infants.  The  cemeteries  bear  witness  to  the  truth  of  this 
statement.  There  is  no  doubt  that  infants  nursed  at  the 
breast  have  a lower  mortality  and  resist  sickness  better 
than  bottle-fed  babies.  One  would  hardly  believe  that 
a healthy  woman  would  refuse  to  nurse  her  offspring, 
yet  it  is  true  now  and  has  been  for  centuries.  Caesar  re- 
proached the  Roman  women  for  giving  their  children  to 
mercenary  nurses,  and  moralists  of  all  epochs  have  con- 
tended against  the  practice.  Aulius  Gellius,  in  his  Attic 
Nights;  Erasmus,  in  his  Colloquies;  Montaigne,  in  his 
Essays,  and  many  others  besides  physicians  refer  to  and 
condemn  the  custom.  It  has  been  said  that  no  man  be- 
came great  who  was  raised  on  the  bottle. 

The  author  is  glad  to  bear  witness  that  the  modern 
woman  is  recognizing  more  and  more  the  right  of  her 
babe  to  her  personal  care  and  to  be  nourished  at  her 
own  breasts.  The  argument  of  the  ancient  philosophers 
is  triumphing  at  last.  Nowadays  the  mother  considers 
it  little  less  than  a calamity  when  she  cannot  nurse 
her  infant.  Unfortunately,  many  women  have  undevel- 
oped breasts  or  a gland  that  secretes  nothing,  or  nipples 
that  a child  cannot  grasp,  or  her  general  health  is  so 
poor — from  tuberculosis,  for  example — that  nursing  is 

1 This  chapter  was  thoroughly  revised  by  Dr.  F.  X.  Walls. 

392 


CONTRAINDICATIONS  TO  MATERNAL  NURSING  393 

impossible.  In  these  cases  a wet-nurse  must  be  em- 
ployed or  artificial  feeding  be  instituted. 

Contraindications  to  Maternal  Nursing.  -These 
are:  General  poor  health  from  tuberculosis;  severe 
anemia;  advanced  Bright’s  disease;  severe  epilepsy, 
insanity;  diabetes;  diseases  of  the  breasts,  as  abscess  and 
mastitis;  absence  of  nipples;  inverted  nipples,  and  when 
the  milk  does  not  agree  with  the  infant. 

Honest  effort  should  be  made  to  get  the  breasts  into  a 
condition  satisfactory  for  nursing,  and  patience  should 
prevail. 

If  the  mother  cannot  nurse  her  child,  the  employment 
of  a wet-nurse  should  be  suggested.  This  is  usually 
met  with  great  disapproval  or  even  absolute  refusal,  but 
the  nurse  should  aid  the  doctor  in  trying  to  convince  the 
family  that  human  milk  is  best  for  the  baby.  Often 
one  will  have  to  compromise  on  bottle  feeding  for  a time 
to  see  if  it  agrees  well,  with  the  understanding  that  if  the 
child  does  not  thrive,  a wet-nurse  is  to  be  obtained.  For 
premature  infants  or  those  that  are  not  flourishing  on 
bottle  feeding  no  compromise  may  be  made — mothers’ 
milk  must  be  obtained  at  any  expenditure  of  effort  or 
money. 

If  the  mother  can  nurse  part  of  the  time,  it  is  better 
than  nothing,  and  prepared  milk  is  given  to  complete 
the  feeding.  Mothers’  milk  is  a living  thing,  not  simply 
nourishment,  and  this  is  the  reason  it  cannot  be  success- 
fully imitated.  It  contains  a living  ferment.  The 
author  has  seen  tiny  infants  brought  to  the  maternity 
starved,  weak,  and  faint,  and  after  even  a single  nursing 
they  have  revived  as  if  strong  cordial  had  been  admin- 
istered. It  is  often  observed  that  when  the  mother’s 
milk  does  not  agree  with  the  infant,  or  when  there  is  an 
insufficient  supply  during  the  first  weeks,  the  conditions 
disappear  after  the  mother  has  gotten  up  and  out-of- 


394 


INFANT  FEEDING 


doors  and  has  gone  about  her  usual  duties.  The  quality 
of  the  milk  seems  to  alter. 

Sometimes  the  mother’s  milk  is  too  rich  in  fats,  as 
evidenced  by  the  regurgitation  of  heavy  curds  and  pass- 
ing of  undigested  movements,  with  colic.  To  remedy 
this  let  the  child  have  \ ounce  of  pure  water  before 
nursing,  and  reduce  the  time  of  nursing  to  ten  minutes 
or  less.  If  there  is  too  much  sugar  in  the  milk,  as  shown 
by  colic,  green  stools,  and  diarrhea,  the  same  treatment 
is  given. 

For  the  first  condition — excessive  fats — the  physician 
may  advise  the  patient  to  live  on  a more  vegetarian 
diet  and  drink  more  water.  She  is  made  to  take  outdoor 
exercise,  especially  walking.  For  the  excess  of  sugar  in 
the  milk  a reduced  diet  with  much  water  will  also  be 
recommended,  but  the  patient  may  have  some  meat. 
If  the  milk  is  poor  in  fat  and  proteins,  as  shown  by 
chemic  analysis,  a full  diet  of  meat,  vegetables,  and 
cereals  will  be  ordered.  If  this  does  not  improve  the 
quality  of  the  milk,  the  child  will  need  additional 
feedings. 

If  the  mother  can  give  but  one  or  two  nursings  a day 
she  should  be  urged  to  do  so,  or  if  a permanent  wet-nurse 
cannot  be  obtained,  some  poor  mother  might  be  gotten  to 
come  to  the  house  once  or  twice  daily  to  feed  the  infant, 
a sort  of  visiting  wet-nurse,  or  mothers’  milk  might  be 
procured  from  a neighboring  maternity. 

Obtaining-  Milk  for  Analysis. — For  chemic  anal- 
ysis of  human  milk  at  least  2 ounces  are  needed.  This 
is  obtained  with  a breast-pump  which  has  been  pre- 
viously boiled  in  plain  water.  The  first  milk  is  discarded 
unless  the  amount  promises  to  be  scanty,  and  the  last 
milk — the  “ strippings” — is  not  used,  as  it  contains  too 
much  fat.  The  milk  is  poured  into  a clean,  dry,  sterile 
bottle,  corked  (not  with  cotton),  and  sent  to  the  labora- 


SUBSTITUTES  FOR  MOTHERS'  MILK  395 


tory.  The  best  test  of  the  quality  of  the  milk  is  the 
condition  of  the  child. 

Substitutes  for  Mothers’  Milk. — Of  these,  many 
are  vaunted,  but  few  even  come  near  qualifying.  Cows’ 
milk  is  most  generally  used,  modified  to  suit  the  require- 
ments of  the  individual  child,  but  goats’  milk  and  asses’ 
milk  have  also  been  tried,  both  here  and  abroad.  In 
chemic  composition  asses’  milk  comes  nearest  the  human, 
and  in  Paris,  at  one  of  the  maternities,  the  experiment 
of  using  such  milk  was  tried,  but  with  indifferent 
success. 

Cows’  milk  must  be  “modified”  before  it  is  a suit- 
able food  for  an  infant.  The  term  “modified  milk” 
means  milk  that  is  altered  or  changed  by  the  addition 
of  water,  sugar,  etc.,  and  these  modifications  are  un- 
limited. The  principles  which  underlie  the  modifica- 
tion of  cows’  milk  for  infant  feeding  are  two:  First,  to 
change  the  cows’  milk  into  one  resembling  as  closely  as 
possible  human  milk,  and,  second,  to  adapt  the  milk  to 
the  nutritive  requirements  and  digestive  possibilities 
of  the  individual  infant. 

It  is  essential  that  the  composition  of  human  and 
cows’  milk  be  known. 

Table  of  Two  Milks  Compared 


Human. 

Cows'. 

Fat 

3.5  per  cent. 

Protein 

1.5 

4.0 

Sugar 

7-o 

4-3  “ 

Salt 

0.7 

Water 

87.3 

87.0  “ 

The  chief  differences  in  these  milks,  chemically  con- 
sidered, are  in  the  proteins,  the  sugars,  and  the  salts. 

The  fats  are  in  the  same  proportion  in  the  two  milks, 
though  not  of  the  same  kind.  In  the  human  milk  the 


396 


INFANT  FEEDING 


fats  are  less  acid  and  more  easily  assimilated.  The 
protein  of  cows’  milk  is  nearly  three  times  greater  than 
that  of  human  milk,  and  is  also  very  different  in  its  com- 
position, containing  a larger  amount  of  casein  than 
human  milk.  The  sugar  in  cows’  milk  is  less  than  that 
of  human  milk  and  is  of  the  same  kind,  known  as  lactose 
or  milk-sugar.  The  salts  in  cows’  milk  are  three  times 
in  excess  of  those  of  human  milk,  and,  according  to  recent 
research,  the  difficulty  in  the  digestion  of  cows’  milk  is 
in  great  part  dependent  upon  the  excess  of  salts  and  their 
different  chemic  composition. 

From  the  foregoing  it  may  be  seen  that  if  milk  were 
diluted  with  twice  as  much  water  the  proportion  of 
protein  and  salts  would  approximate  the  amount  found 
in  human  milk,  but  with  this  dilution  of  milk  the  fats 
and  sugars  would  be  greatly  reduced,  and  it  would  be 
necessary  to  supply  these  two  ingredients  to  have  the 
mixture  resemble  human  milk.  This  may  be  done  by 
adding  cream  and  milk-sugar  to  the  mixture.  Such  a 
mixture  as  the  following  closely  resembles  human 
milk: 


Cream i part. 

Milk i “ 

Lactose  solution  (5  per  cent.) 4 parts. 


To  render  the  mixture  alkaline  an  alkali  is  to  be  added, 
such  as  lime-water,  5 per  cent.,  or  bicarbonate  of  soda  or 
citrate  of  soda,  2 grains  to  1 ounce  of  pure  milk. 

Such  a food  might  meet  the  first  indication  in  the 
modification  of  cows’  milk,  but  it  might  not  agree  with 
the  second.  No  matter  how  closely  cows’  milk  is  made 
to  approach  human  milk,  there  is  always  a great  differ- 
ence between  them,  and  the  digestive  peculiarities  of  the 
infant  may  demand  special  modification.  In  practice  it 
is  important,  when  giving  a cows’  milk  mixture  to  a 


SUBSTITUTES  FOR  MOTHERS'  MILK 


397 


young  infant  or  to  any  child  for  the  first  time,  to  begin 
with  a much  weaker  food  than  the  nutritive  requirements 
of  the  child  would  indicate,  and  as  soon  as  the  child’s 
tolerance  for  milk  will  permit  the  strength  of  the  formula 
may  be  cautiously  increased. 

The  mixture,  when  first  given  to  an  infant,  should  be 
boiled  at  least  three  to  five  minutes.  Boiling  kills  all 
bacteria  in  milk  and  renders  it  easier  of  digestion  by 
making  impossible  the  formation  of  large  curds  in  the 
baby’s  bowels.  No  attention  need  be  paid  to  the  re- 
puted constipative  effect  of  boiling  milk. 


There  exist  in  most  large  cities  laboratories  for  the  modification  of 
milk,  of  which  the  Walker- Gordon  laboratory  is  a type.  This  labora- 
tory bears  the  same  relation  to  the  physician  regarding  the  infant’s 
food  as  does  the  pharmacy  regarding  drugs.  The  physician  writes  a 
prescription  calling  for  milk  having  certain  percentages  of  fat,  sugar, 
and  proteins,  stating  the  amount  of  each  feeding  and  the  number. 
The  laboratory  prepares,  or  modifies,  the  milk  exactly  according  to 
the  prescription  and  sends  the  bottles  neatly  sealed,  in  a special  basket, 
to  the  patient’s  house.  A sample  prescription  is  here  given: 

1$.  For  Baby  Johnson, 

1200  Calumet  Avenue. 

Fat 3.0  per  cent. 

Sugar 6.0  “ 

Proteins 1.0  “ 

Alkalinity 5.0  “ 

Heat  at  1550  F. 

Number  of  feedings,  7. 

Amount  at  each  feeding,  4 ounces. 

June  1 , igij. 

John  Smith,  M.  D. 


In  the  absence  of  a milk  laboratory,  or  where  this  is 
prohibited  on  account  of  expense  or  by  preference,  the 
nurse  may  modify  cows’  milk  at  home  with  just  as  good 
success.  The  laboratory  is  convenient,  but  not  neces- 
sary. 

In  practice  she  will  need  cream,  milk,  milk-sugar  or 
maltose,  sterile  water,  and  sodium  citrate  (Fig.  199). 


398 


INFANT  FEEDING 


Bottled  milk  is  most  convenient  to  use  for  this  pur- 
pose. In  cities  bottled  milk  is  always  obtainable. 
Bottled  cream  of  a fairly  constant  percentage — about 
1 6 per  cent. — is  also  sold.  In  the  country  and  in  towns 
freshly  skimmed  milk  may  be  used  as  fat-free  milk,  and 
the  skimmed  cream  for  the  cream  dilutions,  as  it  con- 
tains about  1 6 per  cent,  of  fat.  If  one  has  bottled  milk, 
it  is  best  to  use  it  for  all  the  modifications  unless  the  exact 
percentage  of  fat  in  delivered  cream  is  known. 


Fig.  199.— Apparatus  required  for  milk  modification. 


The  cream  is  obtained  from  the  top  of  quart  bottles  of 
milk  that  have  stood  for  eight  hours.  The  upper  6 
ounces  contain  about  16  per  cent,  of  cream.  Milk  is 
obtained  from  the  bottom  of  the  same  bottle.  The 
lower  8 ounces  are  used  as  fat-free  milk,  being  almost 
free  from  cream,  and  this  milk  furnishes  a part  of  the 
proteins  for  the  finished  product.  It  must  be  remem- 
bered that  cream  or  upper  milk  contains  almost  as  much 
proteins  as  the  whole  milk — that  is,  4 per  cent.  The 
“upper”  and  “lower”  milk  can  be  obtained  by  siphon- 


SUBSTITUTES  FOR  MOTHERS'  MILK 


399 


age.  A drinking-tube  is  bent  V shaped,  so  that  one 
limb  is  4 inches  and  the  other  8f  inches  long.  A piece 
of  rubber  tubing  8 inches  long  is  also  provided.  To 
obtain  the  cream  or  “ upper  milk/’  the  rubber  tube  is 


Fig.  2oo. — The  milk  siphon  in  action. 


fastened  on  the  long  arm  of  the  V-tube,  the  tube  is  then 
filled  with  sterile  water,  and  the  rubber  clamped  with 
the  fingers.  The  short  end  is  immersed  in  the  bottle,  and 
the  cream  will  flow  over  into  a graduate  held  underneath 
(Fig.  200). 


400 


INFANT  FEEDING 


To  obtain  the  “ under  milk  ” the  same  tube  is  used, 
but  the  piece  of  rubber  tubing  is  attached  to  the  shorter 
limb.  The  tube  is  filled  with  sterile  water,  the  end  of 
the  rubber  tube  is  clamped  by  the  fingers,  and  the  long 
glass  end  is  put  in  the  bottle.  Its  lower  opening  will 
come  close  to  the  bottom  of  the  bottle  and  fat-free  milk 
will  siphon  over  into  the  graduate.  One  may  pour  off 
the  cream  from  the  top  of  the  milk,  or  one  may  dip  it  out 
with  a special  little  dipper,  but  with  a little  practice  the 
nurse  will  become  dextrous  with  the  siphon,  and  it  is  the 
best  and  cleanest  way.  Two  of  the  ingredients  for  modi- 
fied milk  are  now  at  hand — 16  per  cent,  cream  and  fat- 
free  milk  As  a diluent  boiled  water  is  used,  though 
sometimes  other  liquids,  as  barley-water  or  oatmeal- 
gruel,  may  be  preferred.  Milk-sugar  may  be  weighed 
or  measured  out  in  the  powder.  If  maltose  is  preferred, 
it  is  obtained  in  one  of  the  malted  milk  foods  or  dextri- 
maltose. 

In  practice  the  nurse  dissolves  the  sugar  in  sterile 
water,  adds  the  soda,  and  filters  the  solution  through 
sterile  absorbent  cotton  if  it  is  not  clear.  Now  the  re- 
quired amounts  of  milk  and  cream  are  added,  the  whole 
poured  into  the  thoroughly  cleansed  bottles,  stoppered 
securely,  sterilized,  and  set  away  in  the  ice-box. 

Amount  of  Food  at  a Feeding. — The  amount  of 
food  will  vary  according  to  the  age  and  individuality  of 
the  infant.  A general  rule  might  be  stated,  that  the 
amount  of  food  in  twenty-four  hours  should  equal  one- 
sixth  to  one-eighth  of  the  baby’s  weight.  If  a baby 
weighed  12  pounds,  the  amount  in  twenty-four  hours 
would  be  between  24  and  32  ounces.  In  the  first  six 
months  the  babe  might  have  at  each  feeding  an  amount 
in  ounces  equal  to  its  age  in  months  plus  one. 

The  interval  between  feedings  should  be  of  such 
length  as  will  permit  ample  time  for  digestion.  A four- 


AMOUNT  OF  FOOD  AT  A FEEDING 


401 


hour  interval  during  the  first  year,  even  from  birth,  is 
the  optimum  period.  Many  children  need  food  oftener, 
therefore  in  practice  they  are  fed  every  three  hours, 
which  is  the  minimum  period  that  food  should  be  given 
to  a normal  baby.  The  infant  should  be  allowed  from 
ten  to  twenty  minutes  to  take  his  bottle.  If  the  food 
is  taken  too  hurriedly,  indigestion  may  result,  and  if  too 
long  a time  is  occupied  with  the  bottle,  the  interval  be- 
tween the  feedings  is  encroached  on. 


The  table  presented  here  is  for  an  average  infant.  A small  infant  will 
require  less;  a large  one,  more.  The  frequency  of  the  feedings  will  corre- 
spond with  that  of  the  usual  nursings. 


Period  of  life. 

Number 

of 

feedings. 

Hours 

between 

feedings. 

Night 

feedings. 

Amount  of 
each 
feeding. 

Total  for 
twenty-four 
hours. 

3d  to  7th  day 

7 

3 

I 

l|-2  OZ. 

IO-15  oz* 

2d  and  3d  weeks . . 

7 

3 

I 

2 ~3  j OZ. 

15-22  OZ. 

4th  and  5 th  weeks  1 

6 

3h 

O 

3 §~4  oz. 

20-24  OZ. 

6th  week  to  3d 
month 

5 

4 

O 

4 "5  oz. 

24-32  OZ. 

3d  to  6th  month.. . 

5 

4 

O 

5 -7  oz. 

30-35  OZ. 

6th  to  9th  month  . 

5 

4 

O 

6|-8  oz. 

32-40  OZ. 

9th  to  12th  month. 

5 

4 

0 

1 

7 -9  oz. 

35-45  oz. 

For  feeding  infants  during  the  first  four  weeks  the 
following  formulas  may  be  used: 


Sample  Formulas 


Formula  No.  I — Useful  from  the  third  day  to  end  of  second  week: 


The  nurse  will  take 


Approximate  percentages. 


Cream  (16  per  cent.) 2 ounces.  Fat 2.0  per  cent* 

Milk None.  Proteins 0.5  “ 

Lactose  (milk-sugar) 5 drams.  Sugar 5.0  “ 

Sodium  citrate 4 grains  or 

7 drams  of  lime-water. 

Sterilized  water  to  make. . . 14  ounces. 

Divide  into  seven  feedings,  2 ounces  each. 


26 


402 


INFANT  FEEDING 


Sample  Formulas 

Formula  No.  II — For  use  in  the  third  week: 

The  nurse  will  take  Approximate  percentages. 

Cream  (16  per  cent.) 2>\  ounces.  Fat 2.5  per  cent* 

Milk None.  Proteins 0.6  “ 

Sugar  (lactose) 1 ounce.  Sugar 5.5 

Sodium  citrate 7 grains  or 

10  drams  of  lime-water 
Sterilized  water  to  make. . . 20  ounces. 

Divide  into  seven  feedings,  3 ounces  each. 


Formula  No.  Ill — For  use  in  the  fourth  week: 

The  nurse  will  take  Approximate  percentages. 

Cream  (16  per  cent.) 4 ounces.  Fat 3.0  per  cent. 

Milk 1 ounce.  Protein 1.0  “ 

Sugar  (lactose) 1 “ Sugar 6.0  “ 

Sodium  citrate 10  grains  or 

10  drams  of  lime-water. 

Sterilized  water  to  make. . . 21  ounces. 

Divide  into  six  feedings,  3^  ounces  each. 


The  Caloric  Method.  —Experiments  have  proved 
the  infant’s  stomach  requires  three  to  four  hours  for 
the  digestion  of  a feeding,  which  is  more  time  than  is 
usually  allowed. 

It  has  been  found  that  the  indigestion  usually  laid  at 
the  door  of  the  proteins  is  often  due  to  too  much  fat,  and 
the  troubles  ceased  when  whole  milk  was  substituted  for 
cream  in  the  feeding  mixtures. 

Overfeeding,  as  to  time,  amount,  and  concentration, 
has  been  oftener  recognized  as  the  cause  of  trouble  than 
underfeeding. 

Thus  the  need  has  been  felt  for  some  check  on  the 
amount  of  food  which  the  infant  should  receive,  and 
Heubner,  of  Berlin,  has  suggested  the  caloric  method. 
The  calorie,  or  heat-unit,  is  the  amount  of  heat  required 
to  raise  the  temperature  of  a kilogram  of  water  i°  C. 
In  the  human  these  heat-units  or  calories  are  derived 
from  the  food. 

An  infant  before  the  sixth  month  requires  not  more 


STERILIZATION  OF  MILK 


403 


than  45  calories  per  pound  of  weight  daily,  therefore  a 
child  of  10  pounds  would  require  450  calories  in  its 
daily  food.  About  30  calories  per  pound  are  used  for 
supplying  heat  and  energy,  the  balance  being  used  for 
regeneration  of  tissue  and  to  provide  for  growth. 

1 gram  of  fat  contains  9.1  calories. 

1 “ protein  contains  4.3  calories. 

1 “ carbohydrate  contains  4.3  calories. 

1 ounce  of  cream  (16  per  cent.)  contains  54  calories. 

1 “ milk  (4  per  cent.)  contains  21  calories. 

1 “ skimmed  milk  contains  10  calories. 

1 “ whey  contains  7 calories. 

1 “ sugar  contains  120  calories. 

1 “ malt  contains  100  calories. 

1 “ flour  (barley,  wheaten)  contains  100  calories. 

1 “ most  proprietary  foods  contains  100  calories. 

By  multiplying  the  number  of  ounces  of  these  ingre- 
dients in  the  total  daily  amount  of  food  by  their  caloric 
equivalent  we  obtain  the  total  calories  ingested,  and  may 
decide  if  the  infant  is  obtaining  too  much  food. 

Filling  the  Bottles. — Smooth,  round  bottles  are 
preferred  for  nursing  (Fig.  201).  They  are  thoroughly 
rinsed  with  water  and  cleaned  out  with  a brush  and  soda 
if  there  is  any  scum  on  the  glass.  Then  the  bottles  and 
a funnel  for  filling  are  sterilized.  For  convenience,  the 
feeding  bottles,  funnel,  siphon,  graduate,  and  mixing 
bottle  are  all  sterilized  at  once  at  the  beginning  of  the 
preparation  of  the  infant’s  food  for  the  day.  An  Ar- 
nold sterilizer  is  very  good  for  this  purpose.  The  siphon 
and  tube  should  be  rinsed  clear  after  each  using.  If 
a scum  settles  on  the  glass,  a few  drops  of  nitric  acid  will 
dissolve  it.  The  bottles  are  filled  with  the  required 
amount  of  modified  milk,  stoppered  with  plugs  of  non- 
absorbent cotton,  and  sterilized. 

Sterilisation  of  Milk.  Heating  milk  to  the  boil- 
ing-point (2 1 20  F.)  renders  it  easy  of  digestion  Some 
pediatrists  prefer  to  heat  the  milk  only  to  1550  F.  This 


404 


INFANT  FEEDING 


has  been  found  to  render  the  milk  sufficiently  sterile, 
and  does  not  alter  its  taste.  The  process  is  called  pas- 
teurization, after  the  inventor,  Pasteur.  A special 
pasteurizer  is,  of  course,  desirable,  but  the  nurse  can  do 
very  well,  with  a little  more  trouble,  by  using  a tin  pail 
large  enough  to  hold  the  seven  bottles 
and  tall  enough  to  allow  the  lid  to  be 
adjusted. 

A thick  towel  is  laid  at  the  bottom  of 
the  pail,  the  bottles  set  on  it,  the  pail 
three-quarters  filled  with  cold  water,  and 
quickly  brought  to  a boil.  Just  before 
the  water  begins  to  boil  the  pail  is  re- 
moved from  the  stove  and  set  in  a cool 
place  When  cooled,  the  bottles  are 
placed  on  ice  (Fig.  202).  The  nurse 
may,  also,  bring  the  water  up  to  1550  F., 
as  shown  by  the  thermometer,  and  hold 
it  at  this  temperature  for  fifteen  minutes. 

Before  feeding,  the  milk  is  heated  to 
950  F.,  a plain,  freshly  boiled  rubber 
nipple  is  used,  and  the  baby  fed  by 
hand.  It  is  a bad  practice  to  adjust 
the  bottle  so  the  infant  can  feed  itself. 
The  child  loses  the  nipple  or  sucks  air, 
or  the  milk  flows  around  its  neck,  wet- 
ting the  dress  and  bed  and  causing  colds. 

Milk  not  drunk  at  the  nursing  is  to  be  thrown  away. 
After  nursing,  the  bottle  and  nipple  are  thoroughly  rinsed 
inside  and  out  and  set  aside  in  a clean  place  for  sterik 
ization.  Milk  must  not  be  kept  in  a vacuum  bottle, 
warm,  ready  for  night  feedings. 

Quality  of  the  Milk. — Milk  from  a herd  of  cows, 
or  “mixed  milk,”  is  better  than  “one  cow’s  milk,”  as 
the  variations  of  the  constituents  are  not  so  great  Milk 


Fig.  201. — A 

hygienic  nursing 
bottle. 


QUALITY  OF  THE  MILK 


405 


from  the  fancy  breeds  of  cows  should  not  be  chosen. 
Experience  has  shown  that  the  hardy  breeds,  Durham, 
Ayrshire,  and  Holstein,  give  the  best  milk  for  babies. 

In  cities  to  which  milk  has  to  be  transported  from  long 
distances  pasteurization  or  sterilization  is  usually  neces- 
sary, and  always  in  summer.  If  the  milk  is  obtained 
under  aseptic  precautions,  as  do  the  Walker- Gordon 
companies,  the  “certified  milk”  firms,  and  a few  others, 
raw  milk  may  often  be  used,  though  the  author  prefers 


Fig.  202. — Old-fashioned  ice-box  with  milk  rack  standing  in  ice- water. 


to  sterilize  it  in  addition.  “Certified  milk”  is  a milk 
that  comes  from  disease-free  cattle  that  are  properly  fed 
and  pastured,  hygienically  stabled  and  groomed  before 
milking;  a milk  that  is  received  in  sterile  cans  through 
a gauze  and  absorbent  cotton  filter,  quickly  cooled  to  a 
temperature  below  40°  F.  and  kept  at  this  temperature 
till  it  reaches  the  consumer,  a period  which  should  not 
exceed  twenty-four  hours. 

For  the  methods  of  modification  recommended  in 
this  chapter  milk  bottled  on  the  farm  is  necessary. 


406 


INFANT  FEEDING 


Where  bottled  milk  is  not  procurable,  skimmed  milk 
may  be  used  for  the  “lower  milk”  and  the  cream  that 
has  been  skimmed  off  used  for  the  “upper  milk.”  The 
nurse  must  be  sure  that  the  milk  is  fresh,  that  it  is 
not  contaminated  by  standing  uncovered,  or  by  being 
left  in  a refrigerator  together  with  decaying  vegetables 
or  meat.  Milk  attracts  the  odors  of  other  things  in 
the  refrigerator  and  acquires  a foreign  taste.  A special 

little  refrigerator  ought  to  be 
used  for  the  milk,  and  the 
bottles,  if  they  are  kept  at 
a low  temperature,  should  be 
immersed  up  to  their  necks 
in  ice-water.  Before  a bottle 
is  opened  the  outside  should 
be  carefully  cleansed.  Abso- 
lute asepsis  must  prevail  in 
the  handling  and  the  modi- 
fication of  milk.  A slight 
browning  of  the  milk,  heated 
with  lime-water,  is  due  to 
caramel. 

A convenient  method  for 
the  home  modification  of  milk 
is  the  “materna”  glass  (Fig. 
203).  This  is  a large  paneled 
graduate  with  the  amounts 
of  the  various  ingredients 
needed  for  modifying  milk  to 
suit  the  different  periods  of  infancy  stamped  in  the 
glass  on  each  of  six  panels. 

Whey.  —If  the  “lower  milk”  is  coagulated  with  rennet 
or  junket  tablets  or  essence  of  pepsin  and  the  curd 
strained  off,  the  liquid  remaining  is  the  whey.  To  make 
whey,  the  nurse  takes  1 pint  of  milk  at  body  temperature 


BARLE  Y-  WA  TER 


407 


and  adds  J grain  of  rennet  or  one-half  a junket  tablet, 
dissolved  in  a little  water.  In  thirty  minutes  the  curd 
has  formed.  The  mixture  is  strained  through  a napkin 
without  too  firm  pressure,  and  then  placed  on  ice.  If  it 
is  to  be  added  to  cream,  the  whey  must  first  be  heated  to 
1 550  F.  for  ten  minutes,  or  the  cream  will  curdle. 

Whey  is  a valuable  food,  especially  in  weak,  premature 
infants,  and  in  cases  of  indigestion,  where  human  milk 
cannot  be  obtained.  It  contains  0.5  to  1 per  cent,  of 
proteins,  4 per  cent,  of  sugar,  and  o to  1 per  cent,  of  fat. 
It  may  be  used  instead  of  skimmed  milk,  and  may  be 
added  to  the  various  modifications  given  in  this  chapter. 
It  will  often  be  borne  by  weak  stomachs  when  nothing 
else  agrees.  The  reason  for  this  lies  in  the  fact  that 
the  proteins  of  whey  are  more  digestible  and  resemble 
more  the  proteins  of  human  milk. 

Peptonized  milk  is  sometimes  used  for  a limited 
period.  (See  Dietary,  p.  456.) 

Barley-water.  — Notwithstanding  the  theory  that 
very  young  infants  do  not  digest  starches,  the  writer  has 
found  that  many  of  them  will  exist  on  barley-water  for 
several  days  and  that  digestive  disturbances  will  subside 
under  its  use.  It  is  also  useful  as  a diluent  instead  of 
boiled  water,  and  may  increase  the  digestibility  of  cows’ 
milk. 

Barley-water  is  prepared  as  follows:  Two  tablespoon- 
fuls of  pearl  barley  are  washed,  then  soaked  in  water  for 
three  hours  or  more.  This  water  is  decanted,  and  1 
quart  of  fresh  water  added.  The  mixture  is  allowed  to 
boil  two  hours,  adding  water  to  keep  up  the  amount — 
1 quart.  Strain  through  fine  cheese-cloth.  A pinch 
of  salt  may  be  added  Keep  on  ice. 

A quicker  method  is  practised  by  means  of  Robinson’s 
barley  flour.  Twelve  ounces  of  water  are  slowly  stirred 
into  an  even  tablespoonful  of  the  flour  in  a bowl.  The 


408 


INFANT  FEEDING 


mixture  is  then  boiled  fifteen  minutes  and  strained  as 
before. 

Oatmeal-water  is  prepared  as  is  barley-water.  This  is 
used  where  the  child  is  costive.  If  diarrhea  exists, 
barley-  or  rice-water  is  preferred. 

Beef-juice. — Even  very  young  infants  may  need  a 
preparation  of  beef,  although  the  occasion  is  rare.  Beef- 
juice  is  best  prepared  by  lightly  broiling  a piece  of  lean, 
tender  steak  and  pressing  out  the  juice  with  a meat- 
press  or  lemon-squeezer.  A little  salt  is  added,  the 
required  amount  taken,  and  the  balance  immediately 
put  on  ice. 

The  Cold  Method. — Meat  is  chopped  fine,  put  in  a 
Mason  jar,  and  water  (one-quarter  by  bulk)  is  added. 
The  mixture  is  allowed  to  stand  for  one-half  hour  and 
then  squeezed  through  a meat-press.  Sometimes  a 
few  drops  of  hydrochloric  acid  are  added  or  a pinch 
of  salt. 

Beef-juice  may  be  added  to  modified  milk,  to  barley- 
water,  or  given  plain,  well  diluted. 

Extract  of  beef  is  useless  for  infant  feeding.  Com- 
mercial preparations  of  beef — as  peptonoids,  beef-jelly, 
etc. — are  seldom,  if  ever,  needed.  The  writer  believes 
that  fresh  meat-juice  prepared  at  home  is  better  than 
preserved  stuffs. 

Artificial  Infant  Foods. — Of  these,  there  are  a 
host  of  advertised  preparations,  including  condensed 
milk.  The  nurse  will  not  be  called  upon  to  recom- 
mend any  given  brand  of  food.  In  spite  of  the  beau- 
tiful pictures  in  the  advertising  columns  of  magazines, 
these  foods  are  generally  harmful  when  used  without 
medical  supervision.  The  physician  may  prescribe  this 
or  that  food  when  he  sees  that  the  child  requires  the 
ingredients  the  given  food  possesses,  but  the  nurse  is  not 
expected  to  do  this.  There  is  no  doubt  that  rickets, 


ARTIFICIAL  INFANT  FOODS 


409 


scurvy,  and  other  constitutional  diseases  and  weaknesses 
are  traceable  to  proprietary  foods.  Babies  that  are  fat 
from  these  foods  are  usually  not  healthy  babies. 

Proprietary  foods  may  be  used  to  help  out  the  breast 
nursing,  to  provide  starch  for  modified  milk  when  this  is 
desired,  when  the  child  is  weaned,  and  for  temporary 
feeding  at  other  times,  all  of  which  are  decisions  to  be 
made  by  the  medical  adviser. 


APPENDIX 


VISITING  NURSING  IN  OBSTETRIC  PRACTICE 

In  many  large  cities  eleemosynary  visiting  nurses’ 
associations  provide  for  the  home  care  of  poor  women 
who  cannot  leave  their  families  to  go  to  a maternity 
for  confinement.  This  is  really  a great  boon  for  poor 
women,  and  is  a long  step  in  the  direction  of  good 
obstetrics. 

Care  During  Tabor  Among  the  Destitute.  It 

would  seem  impossible  to  obtain  anything  like  aseptic 
results  in  the  hovels  and  the  country  huts  in  which  many 
children  are  born,  yet,  with  a little  trouble,  by  simplifying 
the  methods,  one  may  do  as  successful  work  in  such 
practice  as  in  the  best  maternity.  This  is  proved  by  the 
record  of  the  Chicago  Lying-in  Hospital  and  Dispensary, 
where,  out  of  16,000  consecutive  labor  cases  treated 
exclusively  by  the  officers  of  the  institution  in  the  houses 
of  the  poorest  of  Chicago,  only  3 women  have  died 
from  puerperal  infection. 

If  visiting  nurses  are  to  help  poor  women  at  the  time 
of  labor  it  is  necessary  to  provide  certain  aids  for  good 
work,  though  one  can  improvise  everything  but  soap  and 
water.  The  things  requisite  are  taken  to  the  case  in  a 
large  satchel.  Figure  204  shows  the  contents  of  the  one 
used  in  the  service  of  the  Chicago  Lying-in  Hospital 
and  Dispensary. 


411 


412 


APPENDIX 


List  of  Articles  in  Labor  Satchel 


One  pair  rubber  gloves. 

One  pair  leggings. 

One  jar  sterile  cotton  pledgets. 

One  jar  sterile  pads,  and  cord  dressing. 
Three  small  milk  pans  of  granite  ware. 
Two  brushes,  one  box  green  soap. 

Two  towels. 

One  newspaper. 

One  ounce  fluidextract  of  ergot. 


Fig.  204. — The  labor  satchel,  and  its  contents. 


One  bottle  boric  acid  solution. 

One  bottle  lysol. 

One  bottle  bichlorid  tablets. 

One  bottle  tape  for  cord  (sterile). 

One  bottle  1 per  cent,  nitrate  of  silver,  with  medicine- 
dropper. 

One  pair  scissors. 

One  artery  forceps. 

One  baby  scale. 

One  measuring  tape. 

One  pelvimeter. 


VISITING  NURSE  IN  OBSTETRIC  PRACTICE  413 


One  tracheal  catheter. 

One  sterile  soft-rubber  catheter. 

One  douche-can  with  tube  and  point  (sterile). 

One  labor  record,  one  birth  return,  one  visiting  nurse’s 
record. 

On  arrival  at  the  parturient’s  house,  the  patient  is  pre- 
pared by  giving  an  enema,  then  shaving  the  pudendal 
hair,  thorough  scrubbing  with  soap  and  water  from  ensi- 
form  to  knees,  followed  by  a wash  with  1 : 1000  bichlorid. 
A clean  nightdress  and  wrapper  are  put  on  the  patient 
and  the  bed  prepared  with  clean  sheets  if  obtainable. 
If  not,  the  bed  is  spread  with  clean  newspapers.  The 
accumulated  litter  is  removed  from  the  bed  and  room,  also 
all  unnecessary  furniture,  bedding,  children,  dogs,  etc. 

Provision  is  made  for  good  light  and  also  a supply  of 
clean  newspapers.  These  are  used  under  the  patient 
during  delivery,  over  tables,  chairs  carrying  the  solution 
basins,  and,  in  the  absence  of  sheets,  may  be  placed  over 
the  patient  to  protect  her  from  the  dirty  comforters  or 
blankets  often  supplied.  If  there  is  time  the  papers 
are  sterilized  by  baking. 

The  patient  is  delivered  on  the  side,  because  this  carries 
the  pudenda  well  out  of  the  bed,  which  is  likely  to  sag 
deeply.  The  whole  secret  of  doing  aseptic  obstetrics  in 
a city  hovel  or  country  hut  is  to  bear  in  mind  that  only 
the  small  cleansed  area  of  the  vulva  is  sterile,  and  every- 
thing else  in  the  environment  is  infected.  If  every- 
thing that  comes  in  contact  with  the  vagina  and  this 
small  sterilized  area  is  aseptic  (e.  g .,  hands,  sponges, 
instruments),  the  woman  will  not  be  infected. 

When  the  child  is  born  it  is  laid  in  a clean  towel,  and 
after  the  cord  is  cut  the  stump  is  dressed  antiseptically. 
The  babe  is  oiled,  not  bathed,  and  wiped  dry  with  a clean 
towel.  It  is  then  placed  safely  near  the  stove. 

The  placenta  is  received  in  a scalded  plate  or  a folded 


4r4 


APPENDIX 


newspaper,  the  edge  of  which  has  been  wet  with  bichlorid, 
or  in  a sterile  basin  if  obtainable. 

After  delivery  a clean  newspaper  covered  with  a towel 
is  placed  under  the  patient,  or  the  bed  is  dressed  with 
clean  linen.  A roller  towel  is  applied  for  the  binder. 

Duties  During  the  Puerperium.  The  nurse  visits 
the  puerpera  each  morning,  and  spends  one-half  to  one 
hour  with  her  and  the  baby. 

Duties  at  Each  Visit. — The  infant  is  to  be  dressed 
first.  A full  bath  or  inunction  is  given,  the  navel  is 
dressed  aseptically,  and  the  rules  given  under  sections 
on  Care  of  Child  carried  out  as  fully  as  possible.  Until 
the  umbilicus  is  healed  the  child  is  not  to  have  a full  bath, 
because  the  bath-tub  in  such  practice  is  anything  but 
aseptic.  Occasionally  a tin  dish-pan  makes  the  best  bath- 
tub for  later  use.  The  eyelids  are  cleansed  with  plain 
water,  the  diaper  is  changed,  and  the  infant  left  in  as 
comfortable  a place  as  the  house  affords,  away  from  drafty 
cracks  or  windows,  secure  from  the  attacks  of  flies,  mos- 
quitoes, vermin,  and  other  household  pests.  The 
infants  in  this  field  of  practice  suffer  much  from  bowel 
disorders,  which  are  due  to  improper  feeding,  too  fre- 
quent nursing,  errors  of  diet  of  the  mother,  the  adminis- 
tration of  all  sorts  of  teas,  as  saffron  tea  for  jaundice, 
camomile,  fennel  tea,  etc.  Direct  infection  of  the 
intestinal  tract  is  encouraged  by  dirty  bottles,  nipples 
or  fingers,  flies,  etc.  The  nurse  should  admonish  and  in- 
struct the  mother  regarding  these  dangers  and  the  man- 
ner of  avoiding  them,  though  her  efforts  may  not  have 
the  desired  success  through  the  ignorance,  not  the  un- 
willingness, of  the  people.  Infants  under  these  circum- 
stances suffer  much  from  skin  eruptions,  which  are  due 
to  insects,  filth,  coarse  and  cheaply  dyed  garments,  im- 
pure soap  or  oil  used  for  inunction,  wrapping  the  babe 
too  warmly,  and  the  general  unhygienic  surroundings. 


VISITING  NURSE  IN  OBSTETRIC  PRACTICE  415 


Under  such  discouraging  conditions  it  is  remarkable  and 
commendable  that  anything  like  success  in  treatment 
can  be  obtained,  but  an  intelligent  nurse  interested  in  her 
work  can  really  do  wonders.  The  writer  has  seen  evi- 
dences of  this  on  many  sides  in  his  institutional  practice. 

The  nurse  each  day  takes  the  child’s  temperature  and 
records  it,  with  any  unusual  symptoms,  on  the  record- 
sheet  (Fig.  205). 


THE  CHICAGO  LYING-IN  HOSPITAL 
AND  DISPENSARY 

floln  Office  at  Hospital.  294  Ashland  Boulevard 


nf  p#t'Anl  1 

NURSE’S  RECORD -CHILD 

Date...... 

A.  ML 
r m 

Dey.  Temp Poise Rasp..... 

Stools Urine. 


Date 

Dav  Temn 

Stoole 

Sleep 'Nursing Cry. . 

Eyes — « . . ..1 U mbilicua ...... Skin . 

Treatment 


Stools .... 

Sleep 

Eves 

Fig.  205. — Child’s  record-sheet  for  visiting  nurse  (j  size). 


After  the  infant  has  been  attended  to,  the  nurse  gives 
the  mother  some  care.  A full  bath  every  fourth  day  and 
daily  washings  of  face,  hands,  and  axillae  are  sufficient. 
The  breasts  are  dressed,  using  boric  acid  solution  and 
sterile  pledgets,  and  the  binder  applied.  The  binder 
may  be  improvised  out  of  a roller  towel.  The  genitals 
are  washed  with  1 per  cent,  lysol  solution  and  a fresh  pad 
adjusted.  Another  roller  towel  makes  an  abdominal 


4i  6 


APPENDIX 


binder.  A clean  nightdress  and  combing  the  hair  com- 
plete the  toilet. 

It  is  unnecessary  to  say  that  when  dressing  the  navel 
of  the  infant,  the  breasts,  and  the  genitals  of  the  mother 
the  nurse  should  scrub  her  hands  with  green  soap  and 
water  and  sterilize  them  in  lysol  or  bichlorid  solution. 
If  the  visiting  nurse  must  do  other  work  besides  obstetric, 


THE  CHICAGO  LYING-IN  HOSPITAL 
AND  DISPENSARY 

Main  Office  at  Hospital,  294  Ashland  Boulevard 

VISITING  NURSE'S  RECORD- MOTHER 


Name  of  Patient 


.Address. 


Appl.  No.. 


Date "P  Ml Day.  TemP Pulse ....Keep Signature. 

Bowels Bladder General  Condition 

Breasta Nipples Milk 

Uterus  ( height  above  pubis ) Tenderness Lochia 

Treatment 


Date P M Day.  TemP Pulse Reap Signature . 

Bowels Bladder General  Condition 


ureasis 

Uterus  (heigh  above  pubis) 

p*  Day.  Temp Pulse 

Resp Signature : 

Bladder 

Fig.  206. — Mother’s  record-sheet  for  visiting  nurse  (M  size). 


such  as  dressing  ulcers,  abscesses,  attending  pneumonia 
cases,  the  precautions  she  is  required  to  take  are  much 
more  rigorous.  It  would  be  better  if  the  duties  could  be 
dissociated. 

The  obstetric  work  must  be  done  first  in  the  morning; 
the  nurse  should  wash  her  hands  with  especial  care  before 
touching  aseptic  things  and  wounds  (the  navel,  breasts, 
and  genitals),  and  she  should  sterilize  her  hands  each 


VISITING  NURSE  IN  OBSTETRIC  PRACTICE  4 1 7 

time  after  touching  an  infected  case.  The  use  of  rubber 
gloves  will  spare  the  skin  many  of  the  discomforts 
caused  by  frequent  sterilizations  and  corroding  anti- 
septics. Rubber  gloves  find  their  greatest  usefulness 
in  district  nursing. 

After  dressing  the  patient,  the  bed  is  made  as  nicely  as 
possible  with  the  linen  available,  and  the  patient’s  tem- 
perature and  pulse  taken  and  recorded,  together  with 
such  other  items  of  interest  as  the  nurse  may  discover. 
The  nurse  also  records  what  services  she  rendered  and  the 
length  of  time  of  the  visit  (Fig.  206).  She  secures  suffi- 


Fig.  207. — The  visiting  nurse’s  satchel  and  its  contents. 


cient  ventilation  in  the  lying-in  room,  if  this  is  possible, 
and  sees  that  the  litter  and  accumulated  rubbish  are 
removed.  She  instructs  the  patient  and  the  family  as  to 
the  importance  of  cleanliness  in  these  cases,  and  tries  to 
obtain  for  the  patient  as  comfortable  and  undisturbed  a 
puerperium  as  the  circumstances  will  permit. 

If  an  enema  is  to  be  given,  the  nurse  attends  to  this, 
or  instructs  some  member  of  the  family  to  do  it.  If  there 
are  sutures  in  the  perineum,  the  nurse  had  better  give  it 
herself. 

In  order  to  do  this  work  well,  the  articles  needed 

27 


418 


APPENDIX 


should  be  taken  by  the  nurse  to  the  case.  Fig.  207 
shows  such  an  outfit,  being  the  one  used  by  the  nurses 
of  the  Chicago  Lying-in  Hospital. 

List  of  Articles  in  Postpartum  Visiting  Bag 

One  brush  and  one  tin  box  green  soap. 

One  pan  for  hand  solution. 

One  jar  of  cotton  or  gauze  pledgets. 

One  jar  of  vulval  and  umbilical  pads. 

One  towel  for  nurse’s  hands. 

One  bottle  of  saturated  solution  of  boric  acid. 

One  bottle  of  sterile  bobbin  for  retying  cord  if  neces- 
sary. 

One  bottle  of  bichlorid  tablets  labeled  “Poison." 

One  bottle  of  lysol  labeled  “Poison.” 

(All  poisons  are  kept  in  brown  bottles  and  plainly 
labeled.) 

Extra  history-sheets. 

Visiting  nursing  is  becoming  more  and  more  in  demand 
by  people  in  moderate  circumstances;  they  are  unable  to 
employ  a trained  nurse,  but,  by  having  skilled  service  for 
the  morning  attentions,  they  manage  to  do  very  well  the 
rest  of  the  day  with  what  help  the  family  may  render. 

This  is  a very  good  plan  from  very  many  points  of 
view.  For  the  patient,  it  provides  good  scientific  care; 
for  the  doctor,  a security  from  uncleanly  interference  in 
his  work,  and  it  opens  up  a field  of  nursing  to  which 
those  nurses  who  cannot  stand  the  strain  of  continual 
service,  night  and  day,  may  go.  The  plan  is  simple,  the 
nurse  going  to  the  house  in  the  morning  and  rendering 
such  attentions  as  the  case  demands.  Naturally,  she 
will  find  more  favorable  surroundings  and  more  things 
to  work  with  than  in  the  eleemosynary  practice  just 
referred  to. 


IIOPSITAL  VS.  HOME  NURSING 


419 


HOSPITAL  ys.  HOME  NURSING 

One  would  think  that  hospital  and  home  nursing  are 
identical,  and  so  they  are  in  principle,  but  they  differ 
much  in  practice.  The  methods  described  in  this  book 
apply  equally  as  well  to  hospital  as  to  home  practice. 
The  same  diligent  and  consistent  antisepsis  must  be 
practised  in  the  home  as  in  the  hospital.  Statistics 
prove  conclusively  that  more  women  die  from  infection 
at  home  than  in  the  maternities.  While  formerly  the 
maternity  was  a dreadful  place,  with  a mortality  of  10 
per  cent,  or  more,  now  a well-conducted  lying-in  hospital 
is  the  safest  refuge  for  the  parturient  woman. 

The  dangers  of  infection  are  here  known  and  avoided, 
while  in  the  home  the  attendants  work  in  fancied  secur- 
ity. Some  lying-in  hospitals  have  no  mortality  from 
infection  year  after  year.  The  methods  of  sterilization 
practised  in  hospitals  and  at  home  will  be  considered  in 
the  next  chapter;  here  need  be  emphasized  only  the 
danger  of  carrying  infection  from  one  patient  to  another 
in  hospitals. 

Ward  Care. — A large  number  of  puerperae  should  not 
be  put  in  one  ward,  five  beds  being  considered  enough, 
even  with  free  ventilation.  The  nurse  should  remember 
that  even  a healthy  puerpera  may  infect  the  one  in  the 
next  bed.  This,  of  course,  is  especially  likely  if  a puer- 
pera is  not  well — has  fever  or  fetid  lochia.  The  nurse, 
therefore,  between  dressings  must  sterilize  her  hands 
and  provide  fresh  antiseptic  solutions  and  pledgets. 

Should  any  patient  have  an  odor  to  the  lochia,  if  the 
vulva  becomes  swollen,  or  little  gray  patches  appear,  and 
especially  if  the  puerpera  begins  to  be  feverish,  the  nurse 
must  immediately  notify  the  head  nurse  on  the  floor,  who 
will  notify  the  physician.  The  nurse  at  once  adopts 
extra  precautions  until  the  patient  is  ordered  isolated. 


420 


APPENDIX 


These  are : Setting  aside  special  basins,  pitcher,  and  bed- 
pan  for  the  use  of  the  suspected  case,  and  the  wearing  of 
rubber  gloves  when  dressing  her.  These  gloves  are  to 
be  sterilized  after  each  dressing  Pads  from  the  vulva 
must  not  be  touched  by  the  fingers,  but  are  to  be  handled 
with  dressing  forceps  and  burnt  at  once.  Indeed,  the 
entire  dressing  may  be  made  by  means  of  the  forceps. 
It  is  convenient  to  throw  all  pads,  etc.,  into  large  paper 
bags  or  wrap  them  in  newspapers  (see  Fig.  151).  The 
bed  linen  is  soaked  one  hour  in  3 per  cent,  carbolic  solu- 
tion before  being  sent  to  the  laundry.  In  this  manner 
the  spread  of  infection  may  be  prevented.  If,  in  hospital 
work,  infection  is  carried  from  one  patient  to  another,  it 
is  a lasting  disgrace. 

In  the  nursery  the  same  diligent  watchfulness  is 
required  to  prevent  infection  of  the  eyes,  mouth,  navel, 
and  intestinal  canal  from  being  carried  from  one  baby  to 
another.  The  nurse,  therefore,  looks  for  the  first  signs 
of  ophthalmia,  for  the  first  spot  of  thrush  on  the  tongue 
or  gums,  for  the  first  irritation  around  the  navel,  and  for 
the  first  evidence  of  intestinal  disorder  in  the  bowel  move- 
ments. If  an  infant  presents  evidences  of  a beginning 
conjunctivitis  or  any  other  infection,  it  must  be  isolated 
at  once  and  the  head  nurse  notified. 

Dresses  and  linen  from  the  infant  are  to  be  soaked  an 
hour  in  a 3 per  cent,  carbolic  acid  solution  before  being 
sent  to  the  laundry;  the  nurse  provides  completely 
separate  utensils  for  it,  and  does  not  touch  any  of  the 
other  children  in  the  nursery  before  she  has  carefully 
disinfected  her  hands.  As  soon  as  the  nature  of  the  case 
is  fully  declared,  the  physician  will  give  instructions  re- 
garding the  further  treatment. 

It  is  hardly  less  of  a disgrace  than  carrying  infection, 
if  in  a nursery  ophthalmia  is  carried  from  one  child  to 
another,  if  thrush  attacks  the  mouths  of  several  babies, 


HOSPITAL  VS.  HOME  NURSING 


421 


if  a navel  infection  appears,  or  if  an  epidemic  of  intestinal 
disorder  sickens  a number  of  the  children.  Epidemics 
of  thrush  in  lying-in  hospitals  are  due  to  errors  in  steril- 
izing the  nursing-bottles  and  nipples,  letting  several  chil- 
dren use,  without  boiling,  the  same  nipple,  and  carrying 
the  infection  from  one  mouth  to  another  on  the  finger. 
These  same  causes  obtain  for  intestinal  infection.  Epi- 
demics of  umbilical  infection  are  very  rare,  and  are 
always  proof  of  grossest  carelessness  somewhere.  An 
epidemic  of  pneumonia  may  start  from  a “cold  in  the 
head.” 

While  there  is  danger  of  the  communication  of  infec- 
tion through  the  air,  contact,  direct  or  indirect,  is 
responsible  for  the  largest  number  of  cases. 

Recording  of  Symptoms.  -The  hospital  nurse 
should  remember  to  record  and  report  to  her  senior  every 
unusual  symptom  observed  in  either  mother  or  babe. 
Now  her  duty  is  ended,  and  any  oversight  will  not  be 
laid  at  her  door. 

In  general,  the  nurse  should  carefully  and  neatly  chart 
the  usual  entries,  as  pulse,  temperature,  and  respiration, 
and  all  unusual  occurrences.  A neat,  accurate,  and  com- 
plete history-sheet  is  an  indication  of  a good  nurse. 

Prevention  of  Accidents. — Every  year  the  author 
hears  of  an  accident  occurring  in  a hospital,  such  as 
burns  with  hot-water  bottles,  overdose  of  medicine,  bi- 
chlorid  poisoning  from  douches,  etc.  Ordinarily,  phys- 
icians recommend  the  hospital  with  considerable  con- 
fidence, but  the  frequency  of  such  accidents  will  do 
much  to  destroy  this  feeling. 

Can  they  be  prevented?  Yes,  in  almost  every  case. 
Once  in  a while  a combination  of  circumstances  will 
occur  that  no  human  mind  could  foresee,  but  this  is 
rare.  Usually,  some  one  has  blundered,  and,  in  the 
author’s  experience,  carelessness,  thoughtlessness,  and 


422 


APPENDIX 


a slipshod  method  of  work  are  more  often  to  blame  than 
ignorance.  While  in  an  institution  every  one  is  expected 
to  do  his  whole  duty  and  do  it  well,  and  do  it  well  all  the 
time,  the  nurse  cannot  rely  implicitly  on  every  one  else, 
but  must  use  her  own  judgment  to  see  if  those  things 
concerning  her  and  her  work  are  done  right.  For  ex- 
ample, if  the  night  nurse  makes  carbolic  solution  and 
the  day  nurse  sees  pure  acid  floating  at  the  bottom  of 
the  bottle,  she  will  not  use  it  for  fear  of  burning  the 
patient.  If  another  nurse  fills  a hot-water  bottle  for  her, 
she  should  herself  test  its  heat  before  applying  it  to  the 
patient. 

Too  much  caution  cannot  be  enjoined  regarding  the 
use  of  poisons.  A nurse  should  not  administer  a poison 
unless  she  knows  its  nature,  its  physiologic  action,  and 
its  dosage.  Not  knowing  any  one  of  the  three,  she 
should  inform  herself  at  the  earliest  moment.  To  avoid 
administering  poison  by  mistake  all  bottles  containing  it 
should  be  of  colored  glass,  or  special  poison  bottles  are  to 
be  used;  they  should  be  plainly  labeled  “poison,”  and  the 
nurse  should  read  the  label  once  before  and  once  after 
measuring  off  the  required  amount. 

Orders. — A continued  order  is  one  that  is  kept  up 
day  after  day.  As  such  orders  are  often  copied  from  one 
history- sheet  to  another,  or  from  one  medicine-slip  to 
another,  the  nurse  must  be  accurate  in  carrying  them 
over.  Should  she  notice  an  error,  or  what  seems  to  be 
an  error,  in  the  copying,  she  should  consult  the  head 
nurse  before  administering  the  dose.  In  hospitals 
continued  orders  are  liable  to  be  carried  longer  than  really 
necessary,  and  in  such  cases  the  nurse  is  justified  in 
asking  the  physician  if  she  should  continue  this  or  that 
medicine. 

The  nurse  should  not  accept  verbal  orders,  but  should 
hand  the  history-sheet  or  order  book  to  the  physician  for 


HOSPITAL  VS.  HOME  NURSING 


423 


his  entry.  If  the  order  is  given  by  telephone  she  should 
enter  it  “Verbal  Order,  Dr.  X.,”  giving  exact  time. 

Relations  to  the  Patient.  -Most  people  dread  even 
the  word  hospital,  and  this  dread  is  not  unfounded.  If 
the  word  “hospital”  could  be  made  identical  in  meaning 
with  the  word  “home,”  this  dread  would  vanish.  It  is 
the  hospital  nurse’s  duty  to  make  each  patient  feel  as  if 
she  was  in  her  own  home.  It  is  pleasantly  surprising 
how  much  can  be  done  in  this  direction  if  only  the  will 
is  there.  An  obstetric  case  is  more  than  a medical  case, 
and,  in  addition  to  aseptic  and  skilful  nursing,  the  ex- 
pectant mother  requires  womanly  sympathy.  She  must 
not  be  treated  as  “material.”  A hospital  can  be  deco- 
rated and  furnished  very  much  like  a home  without 
straining  the  requirements  of  asepsis;  if  hospital  authori- 
ties would  appreciate  this  fact,  the  modern  movement  in 
favor  of  hospitals  for  the  sick  would  receive  remarkable 
impetus.  But,  finally,  it  is  the  nurse — the  personality 
of  the  nurse — that  makes  the  atmosphere  around  the 
institution,  just  as  it  is  the  spirit  of  the  hostess  that 
breathes  in  every  object  about  the  home. 

Economy.  -The  hospital  nurse — and  the  hospital 
doctor — must  often  be  accused  of  wastefulness.  Most 
hospitals  are  supported  either  wholly  or  in  part  by  money 
contributed  by  the  charitably  inclined.  It  often  requires 
the  most  strenuous  efforts  of  a large  board  of  managers 
to  raise  funds  sufficient  to  meet  current  expenses  and  to 
provide  the  improvements  needed.  The  public  has  a 
right  to  demand  that  hospital  authorities  expend  the 
money  intrusted  to  them  in  the  most  economic  manner, 
so  that  the  largest  number  may  receive  the  benefit. 
Wilfully  or  thoughtlessly  to  increase  the  cost  of  conduct- 
ing an  institution  is  to  limit  the  institution’s  power  of 
doing  good,  and  some  one  will  suffer.  Further,  some  one 
will  have  to  give  the  money  to  make  up  the  loss  caused 


424 


APPENDIX 


by  wastefulness.  Wilful  wastefulness  is,  therefore,  very 
close  to  stealing. 

The  nurse  who  is  extravagant  with  linen  throws  un- 
necessary work  on  the  laundry.  If  foods  are  allowed  to 
spoil,  the  culinary  department  shows  a needless  deficit. 
If  gauzes,  sponges,  and  dressings  are  wasted,  the  medi- 
cal supply  bills  become  too  large.  All  these  drains 
together  make  a burden  which  might  prove  too  much 
for  the  institution.  “Little  wastes  in  great  establish- 
ments, constantly  occurring,  may  defeat  the  energies 
of  a mighty  capital”  (Lyman  Beecher). 

METHODS  OF  STERILIZATION 

Obstetric  asepsis  while  equally  as  minute  as  surgical, 
is  much  less  cumbersome.  There  is  one  fundamental 
difference  in  the  technics  of  the  two  arts — the  fact  that 
the  obstetrician  is  always  working  in  or  near  an  infected 
field.  The  vagina  is  seldom  really  sterile,  and  the  rectum 
is  so  close  to  the  field  of  operation  that  it  is  a constant 
menace.  The  accoucheur,  therefore,  cannot  practice, 
during  a labor,  the  nice  aseptic  methods  of  the  surgeon; 
he  must  practice  antisepsis.  As  far  as  dressings,  sutures, 
etc.,  are  concerned,  the  accoucheur  insists  on  their  being 
absolutely  aseptic,  as  does  the  surgeon. 

The  fact  that  the  obstetric  case  cannot  be  handled  as  a 
clean  surgical  case  does  not  excuse  either  doctor  or  nurse 
from  responsibility  if  the  patient  sickens  from  infection. 
If  both  doctor  and  nurse  have  conscientiously  and  con- 
sistently carried  out  the  best  methods  of  antisepsis  known, 
and  even  then  the  patient  takes  ill  of  infection,  both  may 
feel  that  they  are  blameless  in  this  regard — but  only 
under  the  condition  mentioned. 

Sterilisation  of  the  Hands.  -Scientifically,  it  is 
impossible  to  sterilize  the  hands.  Germs  may  be  found 
in  the  skin  after  all  sterilizations  as  usually  practised. 


METHODS  OF  STERILIZATION 


425 


Practically,  it  has  been  found  that  several  methods  give 
good  results. 

The  most  important  factor  in  being  able  to  sterilize  the 
hands  is  not  to  get  them  infected.  The  day  has  passed 
when  a physician  could  dabble  his  fingers  in  pus  and  then 
feel  clean  after  washing  them. 

Never  get  any  infectious  material  of  any  kind 
on  the  hands!  All  such  things  should  be  touched  with 
forceps  or  rubber  gloves,  and  they  should  not  be  allowed 
to  contaminate  the  clothing. 

Take  good  care  of  the  skin,  so  that  the  epidermis  is 
always  smooth  and  free  from  cracks  and  fissures.  The 
arts  of  the  manicure  may  not  be  despised.  It  is  not 
vanity  that  prompts  the  obstetric  nurse  to  desire  smooth , 
white  hands. 

1.  Fiirbringer’s  Method.  -Pare  finger-nails  and  re- 
move subungual  dirt  with  a dull  instrument  Scrub  for 
from  five  to  ten  minutes  with  hot  water  and  green  soap. 
Soak  hands  in  95  per  cent,  alcohol  for  one  minute.  Soak 
in  1 : 1000  bichlorid  three  minutes. 

Sublamin,  a new  mercury  preparation,  is  now  used  in 
place  of  bichlorid,  in  the  same  proportions.  It  is  said  to 
injure  the  hands  less  and  to  be  as  strongly  bactericidal. 

2.  Hot  Water  and  Alcohol  Method  of  Ahlfeld.  -Pare 
finger-nails  and  remove  subungual  dirt  Scrub  with  soap 
and  hot  water  for  from  three  to  five  minutes;  95  per  cent, 
alcohol  rubbed  in  three  to  five  minutes  with  flannel,  which 
wraps  the  hand  until  ready  to  operate.  Ahlfeld  claims 
that  this  method  will  produce  perfect  sterilization  of  the 
skin. 

3.  Halsted’s  Permanganate  Method.  -Pare  finger- 
nails and  remove  subungual  dirt.  Scrub  with  soap  and 
hot  water  for  from  five  to  ten  minutes.  Immerse  hands 
and  forearms  in  hot  saturated  solution  of  permanganate 
of  potash  until  arms  are  stained  deep  brown.  Immerse 


426 


APPENDIX 


in  saturated  solution  of  oxalic  acid  until  skin  is  decolor- 
ized. Rinse  in  sterile  water  or  sterile  lime-water.  Some 
surgeons  use  bichlorid  in  addition. 

4.  Author’s  Method.  -Wash  the  street-dirt  from  hands 
and  forearms,  using  much  soap  and  working  the  soap 
well  under  the  nails,  which  should  be  short.  Clean 
under  the  nails  with  a dull  metal  nail-cleaner.  Scrub  in 
hot  running  water  and  green  soap  for  ten  minutes. 
Scrub  in  1 per  cent,  lysol,  or  1 : 1000  bichlorid  or  1 : 1000 
sublamin,  or  both,  three  full  minutes.  Scrub  in  95  per 
cent,  alcohol  one  minute. 

When  scrubbing  the  skin,  a sterile  brush  made  of 
tampico  fiber  should  be  used.  These  brushes  may  be 
boiled;  bristle  brushes  stand  boiling  poorly.  The  folds 
of  the  fingers  and  palms  must  be  opened  up  so  that  the 
fibers  of  the  brush  can  get  into  them.  To  get  the  fibers 
of  the  brush  under  the  nails  the  fingers  must  be  stretched 
out.  This  draws  the  finger-tip  from  the  nail.  If  the 
finger-tips  are  pressed  together,  the  brush  cannot  get 
under  the  nail.  The  whole  hand  and  forearm  must 
be  gone  over  systematically,  so  that  no  portion  is 
missed. 

N.  B. — After  the  hands  are  sterilized,  it  requires  con- 
stant thoughtfulness  to  prevent  one  from  infecting  them 
by  touching  unsterile  objects. 

Rubber  Gloves. — These  are  by  all  means  the  best 
method  of  aseptic  operating,  but  the  gloves  must  be 
perfect  and  sterile.  Before  putting  on  gloves  the  hands 
are  to  be  sterilized  in  the  usual  manner.  Some  operators 
use  cotton  gloves  and  some  draw  them  on  over  the 
rubber  gloves. 

Methods  of  Sterilizing  Gloves. — (1)  Boiling  in  plain 
water  for  twenty  minutes  and  putting  on,  wet  with  some 
antiseptic  solution.  (2)  Boiling  in  water  for  twenty 
minutes;  drying  by  sterile  hands;  powdering  with  ster- 


METHODS  OF  STERILIZATION 


427 


ile  talcum  or  starch,  inside  and  out;  wrapping  in  sterile 
towels  for  future  use. 

Whenever  the  nurse  boils  gloves  or  rubber  of  any 
kind,  as  colpeurynters  or  douche-bags,  she  should  wrap 
them  securely  in  at  least  four  layers  of  thick  toweling; 
otherwise  they  will  be  scorched  and  ruined  by  lying 


Fig.  208. — Testing  rubber  gloves  by  overfilling  with  very  hot  water. 

against  the  hot  metal.  Rubber  gloves  do  not  stand  fre- 
quent boiling,  becoming  swelled  and  brittle.  They  will 
last  a much  greater  length  of  time  if  steamed  in  the 
steam  sterilizer. 

Author's  Method  of  Sterilizing  Rubber  Gloves. — The 
gloves  are  tested  for  imperfections  by  filling  them  up 
with  very  hot  water  and  drying  the  outside  (Fig.  208). 


428 


APPENDIX 


If  the  water  escapes,  even  in  the  smallest  amount,  the 
glove  is  discarded.  Another,  but  not  as  good,  way  is  to 


Fig.  209. — Author’s  glove  sterilizer.  The  gloves  are  first  sterilized,  hanging 
free  in  the  steam  chamber.  With  sterile  hands  they  are  wrapped  loosely  in 
paper,  two  distinct  wrappings,  enclosing  also  a bottle  of  talcum  or  starch  powder. 
Now  they  are  sterilized  again  for  forty-five  minutes,  dried  thoroughly  on  the 
radiator,  and  stored  in  a clean  box. 


hold  the  inflated  glove  under  water,  when,  if  there  is  a 
puncture,  a tiny  stream  of  air-bubbles  will  escape  from 


METHODS  OF  STERILIZATION 


429 


it.  The  gloves  are  washed  thoroughly  inside  and  out 
with  soap  and  water,  and  then  with  hot  1 per  cent,  lysol 
solution.  They  are  carefully  dried  inside  and  out  and 
then  laid  in  a box  with  a good  supply  of  talcum  powder. 
The  box  is  shaken  briskly,  covering  the  gloves  generously 


Fig.  210. — Showing  how  articles  hang  in  the  steam  chamber.  The  paper  to 
wrap  the  gloves  in,  the  2 -dram  vials  full  of  talcum  or  starch,  and  the  towels, 
on  which  to  do  the  work  of  wrapping,  are  all  sterilized  together. 


with  powder.  The  gloves  are  then  turned  outside  in  and 
the  powdering  process  repeated.  A special  glove  steril- 
izer may  be  employed,  or  the  gloves  may  be  placed  in  any 
steam  sterilizer  (Figs.  209,  210).  Hot  air  should  not  be 
turned  into  the  sterilizer.  A piece  of  cotton  is  laid  inside 
each  glove,  and  it  is  then  wrapped  loosely  in  a towel  or 


430 


APPENDIX 


paper.  They  should  be  sterilized  alone  in  the  apparatus, 
being  placed  as  far  from  the  flame  as  possible,  and  the 
steam  should  flow  forty-five  minutes.  If  a high-pressure 
apparatus  is  used,  thirty  minutes  are  sufficient.  When 
taken  out,  the  gloves,  inclosed  in  their  sterile  towels, 
should  be  wrapped  in  sterile  paper  or  laid  away  in  a clean 
box.  Before  using  them  the  operator  washes  off  the 
talcum  powder  with  alcohol  or  antiseptic  solution. 

The  author  has  used  gloves  prepared  in  this  way  for 
fourteen  years  with  complete  satisfaction. 


Fig.  211. — The  Rochester  sterilizer. 


Sterilisers. — For  practical  sterilization  it  is  not 
necessary  to  have  the  majestic  and  expensive  sterilizers 
used  by  most  hospitals.  Moist  steam  under  moderate 
pressure  will  kill  all  germs  in  forty  minutes.  If  the  steam 
is  very  dry,  as  occurs  in  high-pressure  sterilizers  or  auto- 
claves, the  germs  are  not  so  readily  killed.  Low-pressure 
sterilizers,  as  the  Arnold,  the  Rochester  (Figs.  211,  212), 
or  the  Boeckman,  all  of  which  are  built  on  the  Schimmel- 
bush  plan,  are  very  efficient  because  the  steam  is  wet. 
and  experiment  and  experience  have  shown  that  very 
reliable  results  are  obtained  with  these  instruments. 


METHODS  OF  STERILIZATION 


431 


The  obstetric  nurse  should  possess  a small  portable  ster- 
ilizer which  she  can  send  to  the  houses  of  her  patients; 
there  are  several  on  the  market. 

In  the  absence  of  special  apparatus  the  wash-boiler 
and  the  stove-oven  render  inestimable  service.  The  ob- 
jection to  the  wash-boiler  is  that  the  cottons,  gauzes, 
linens,  etc.,  steamed  therein  become  quite  damp  or  even 
moist.  This  objection  may  be  overcome  by  drying  the 
articles  afterward  in  the  oven  of  the  kitchen  stove,  taking 
care  that  they  are  not  burned. 


Fig.  212. — The  Rochester  sterilizer  open. 


Sterilisation  by  Dry  Heat.  The  oven  of  the  stove 
may  be  used  for  sterilizing  all  supplies  save  rubber  and 
suture  material.  The  oven  should  be  heated  to  the  tem- 
perature required  to  bake  bread,  and  articles  to  be  steril- 
ized are  kept  in  it  for  three  hours.  Newspapers  should 
be  wrapped  around  them,  and  the  required  heat  is  shown 
by  the  light  browning  of  the  paper.  Great  care  is  neces- 
sary to  prevent  scorching  of  linen  and  gauze.  The 
writer  has  only  occasionally  made  use  of  this  method 
of  sterilization. 

Sterilization  by  means  of  antiseptic  solution  is  rarely 
employed  for  dressings,  gauzes,  linens,  etc.  For  tables, 


432 


APPENDIX 


beds,  walls,  etc.,  scrubbing  with  soap  and  water  and 
then  with  an  antiseptic  solution  is  usually  deemed 
sufficient,  because  sterile  things  are  not  supposed  to 
touch  them. 

PREPARATION  OF  INSTRUMENTS 

Obstetric  instruments  should  be  boiled  in  i per  cent, 
soda  or  i per  cent,  borax  solution.  If  no  washing-  or 
baking-soda  is  at  hand,  a little  lysol  or  sodium  hydrate 
will  do.  An  alkali  is  necessary,  because  it  prevents  the 
instruments  from  rusting  and  secures  better  sterilization. 
Boiling  for  five  minutes  in  such  a soda  solution  with  the 
vessel  covered  is  sufficient,  but  if  the  instruments  have 
possibly  been  infected,  a ten-minute  period  is  better. 
If  instruments  are  to  be  kept  aseptic  for  a time  before 
being  used,  the  soda  solution  should  not  be  poured  off 
or  the  cover  removed.  Soft-rubber  goods  are  wrapped  in 
at  least  four  layers  of  a thick  towel  and  boiled  twenty 
minutes  in  plain  water  in  a covered  vessel.  Hard-rub- 
ber instruments  and  tracheal  catheters  must  not  be 
boiled.  They  are  disinfected  by  formaldehyd  vapor  or 
by  immersion  in  strong  bichlorid  solution.  Cystoscopes 
(excepting  the  simple  tubes)  are  disinfected  by  formal- 
dehyd vapor  or  by  lysol  or  carbolic  solutions,  not  bi- 
chlorid. 

After  being  used,  instruments  are  scrubbed  with  a 
brush  and  cold  water,  paying  particular  attention  to  the 
locks,  corrugations,  and  crevices;  then  they  are  rinsed 
in  a hot  i per  cent,  lysol  solution  and  dried  out  of  the 
latter.  Stains  on  the  instruments  are  removed  by  scrub- 
bing with  Sapolio  on  a moist  cloth.  After  use  on  septic 
cases  the  instruments  should  be  boiled  before  being  put 
away.  Imperfections  in  the  instruments  and  loss  of 
nickel-plating  are  to  be  reported  to  the  proper  authority. 
If  a nurse  finds  an  instrument  whose  construction  she 


PREPARATION  OF  DRESSINGS 


433 


does  not  understand,  it  would  be  well  to  learn  about  it 
before  taking  it  apart  or  trying  to  put  it  together,  as  she 
may  do  it  damage. 

STERILIZATION  OF  BRUSHES 

After  use  on  a septic  case  brushes  are  destroyed.  Old 
brushes  with  very  soft  fibers  are  discarded,  yet  a brush 
must  not  be  so  stiff  that  it  scratches  the  epidermis.  Such 
scratches  become  lodging  places  for  germs.  They  are 
thoroughly  washed  with  soap  and  water,  rinsed,  and  then 
steamed  in  the  sterilizer  for  forty-five  minutes.  Brushes 
are  best  kept  dry,  wrapped  in  cloth  containers.  A 
brush  once  used  is  not  used  again  by  another,  or  for  a 
more  advanced  period  of  the  hand  sterilization.  Brushes 
should  not  be  allowed  to  litter  up  the  washstand;  this  is 
neither  aseptic  nor  tidy  Two  jars  for  brushes  should  be 
at  hand — one  filled  with  sterile,  the  other  for  the  used 
brushes.  Many  errors  of  asepsis  are  committed  in  the 
use  and  care  of  hand-brushes  in  an  otherwise  flawless 
system. 

PREPARATION  OF  DRESSINGS 

Cotton  coming  in  unsealed  cartons  is  not  sterile.  For 
use  as  sponges  or  pledgets,  pieces  of  suitable  size  are 
made  from  the  roll  and  sterilized  in  a pillow-case  or  in 
glass  jars.  Cotton  pledgets  are  better  large  than  small. 
Gauze  pledgets,  as  used  in  surgical  work,  would  be  very 
expensive  in  obstetrics,  as  so  many  are  used,  and  they 
must  be  quite  large.  Cotton  answers  the  purpose  well, 
but  if  gauze  is  preferred,  the  nurse  may  make  a pledget 
of  cotton,  covering  it  with  one  layer  of  gauze.  These 
are  called  “ covered  sponges,”  and  have  all  the  advan- 
tages of  gauze  with  the  cheapness  of  cotton  (Figs.  213- 
216).  These  covered  sponges  are  packed  into  jars, 
covered  with  a layer  of  cotton,  and  sterilized  one  hour  in 
28 


434 


APPENDIX 


PREPARATION  OF  DRESSINGS 


435 


flowing  steam.  The  jars  are  very  loosely  covered  dur- 
ing sterilization;  after  it,  the  covers  are  screwed  down 
tightly. 

Pads  or  vulvar  dressings  are  made  by  folding  a piece 
of  absorbent  cotton  3x8  inches  into  a piece  of  gauze 

12  inches  square,  leaving  the  ends  long.  They  are 
wrapped  in  towels  or  cotton-cloth  sacks,  and  sterilized 
in  flowing  steam  for  one  hour,  dried  in  the  sterilizer,  and 
laid  away  in  a dust-proof  box. 

Newspapers. — One  of  the  handiest  articles  in  the 
lying-in  room  is  the  clean  newspaper.  The  newspaper 
fresh  from  the  press  is  practically  clean,  and  is  very  useful 
to  receive  discharges,  soiled  pledgets,  pads,  etc.,  which 
are  thereupon  wrapped  up  and  burned.  The  nurse 
should,  if  the  opportunity  is  given,  sterilize,  as  she 
would  a package  of  towels,  a bundle  of  clean  news- 
papers. 

Tysol  Gauze  for  Tamponade.  -Two  widths  of 
gauze  are  required  in  packing  the  uterus,  depending  on 
the  time  of  pregnancy.  For  use  in  the  early  months 
a strip  about  3 inches  wide  is  best,  the  gauze  being  cut 
into  5-yard  lengths,  and  loose  threads  carefully  removed 
from  the  edges.  Woven  bandages  are  purchasable  and 
are  preferable  to  cut  muslin.  For  packing  the  uterus  at 
or  near  full  term  these  narrow  strips  would  be  useless. 

Here  the  gauze  is  cut  J-yard  wide,  into  lengths  of 

13  yards.  The  selvedge  and  cut  edge  are  folded  in,  and 
each  length  is  made  into  a bundle.  The  bundles  are 
then  thoroughly  rinsed  in  running  water,  wrung  dry 
by  hand,  and  boiled  for  twenty  minutes  in  0.5  per  cent, 
lysol  solution.  A pair  of  rubber  gloves,  two  sheets,  and  a 
metal  clothes-wringer  are  now  sterilized  by  steam  or 
boiling.  Wearing  the  gloves,  the  nurse  runs  the  bundles 
through  the  wringer,  using  considerable  pressure. 
Then  the  strips  are  packed  into  sterilized  Mason  jars 


Fig.  217. — Gauze  for  uterine  tamponade.  Shows  the  method  of  packing  into 
the  jar  in  layers  from  the  bottom. 


or  others  that  are  large  enough,  packing  smoothly  in 
circles  from  below  upward  (Fig.  217).  Thus  the  tarn- 


PREPARATION  OF  DRESSINGS 


43  7 


ponade  can  be  made  directly  from  the  jar.  The  gauze 
must  not  be  rolled  and  then  placed  in  jars.  The  tops  of 
the  jars  are  filled  with  layers  of  cotton,  the  lids  are  screwed 
down  tight,  and  the  jars  are  put  in  the  sterilizer.  They 
are  sterilized  on  two  successive  days,  two  hours  each 
time.  The  jars  are  then  wrapped  in  three  layers  of 
paper,  sterilized  again,  and  put  away  in  a clean  place. 
Thus  prepared,  gauze  will  keep  sterile  for  years. 

Plain  sterilised  gause  is  prepared  by  cutting 
the  gauze,  as  it  comes  from  surgical  supply-houses,  into 
the  requisite  lengths,  as  just  given,  packing  into  the  jars 
as  described,  and  sterilizing  in  the  steam-chamber  every 
day  for  three  days,  two  hours  each  time. 

High-pressure  sterilizers  if  overheated  will  scorch  the 
gauze,  rendering  it  brittle.  A piece  of  such  gauze  may 
break  off  and  be  inadvertently  left  in  the  wound.  Gauze 
coming  from  surgical  supply-houses  should  not  be  trusted 
unless  it  is  in  sealed  containers. 

Iodoform  gause  is  very  seldom  used  in  obstetric 
practice,  and  the  various  methods  of  preparation  need 
not  be  detailed  here. 

Other  drugs  are  used  in  preparing  gauze,  as  chinosol, 
vioform,  boric  acid,  bichlorid,  thymol;  non-absorbent 
gauze  is  also  sometimes  used  instead  of  the  absorbent. 
From  extensive  experience  the  author  can  recommend 
the  lysol  gauze  as  prepared  in  the  manner  described. 

Gelatin  Gause. — Gelatin  favors  coagulation  of  the 
blood,  and  is  sometimes  used  to  impregnate  gauze  intro- 
duced into  the  uterus  for  the  control  of  postpartum  hem- 
orrhage. In  emergency  2 ounces  of  pure  French  gelatin 
are  dissolved  in  20  ounces  of  boiling  water  and  the  mix- 
ture boiled  vigorously  over  a very  hot  fire  with  constant 
stirring  for  at  least  fifteen  minutes.  The  solution  is 
poured  over  the  gauze  just  before  its  introduction.  In 
hospitals  gelatin  is  prepared  in  10  per  cent,  solution  and 


438 


APPENDIX 


sterilized,  so  as  to  be  always  ready  for  use.  Merck  & Co. 
have  put  on  the  market  a sterile  and  non-toxic  gelatin 
in  sealed  glass  bulbs,  which  is  by  far  preferable. 

Suture  Material.  —In  obstetric  work,  without  doubt, 
silkworm  gut  is  the  best  material  for  suture. 

Method  of  Preparation. — It  should  be  washed  with 
tincture  of  green  soap  and  water,  wound  in  little  rings 
containing  three  strands  each,  boiled  in  plain  water  for 
thirty  minutes,  and  placed  with  sterile  forceps  in  sterile 
glass  bottles  containing  i : 1000  bichlorid.  The  tops  of 
the  bottles  are  covered  with  cotton,  and  in  this  way  the 
gut  will  keep  sterile  for  months.  Some  operators,  and 
especially  those  in  private  practice,  prefer  to  boil  the  gut 
just  before  the  operation  or  with  the  instruments.  The 
nurse  should  see  that  it  is  thoroughly  washed  with  soap 
and  water  first. 

Catgut.  -Many  hospitals  and  most  doctors  in  private 
practice  buy  catgut  already  prepared.  It  comes  in  sealed 
paper  envelopes  or  in  glass  tubes  or  bottles.  The  steril- 
ization of  catgut  is  a difficult  matter,  and  there  are  many 
methods;  for  example:  (i)  Boiling  in  cumol;  (2)  boiling 
in  alcohol  under  pressure;  (3)  boiling  in  saturated  solu- 
tion of  ammonium  sulphate;  (4)  soaking  in  ether,  bi- 
chlorid, alcohol,  and  juniper  oil;  (5)  soaking  in  iodin 
solutions,  (6)  iodoform  solutions,  etc.  The  writer  hardly 
thinks  it  necessary  to  describe  all  these  methods,  and 
refers  the  nurse  to  surgical  text-books  for  the  details. 

Silk. — This  is  not  much  used  in  obstetric  practice.  It 
is  best  prepared  by  thorough  washing  in  hot  water  with 
tincture  of  green  soap,  boiling  in  1 per  cent,  lysol  solu- 
tion for  thirty  minutes,  and  rinsing  thoroughly  in  sterile 
water  just  before  use.  Some  physicians  sterilize  it  in  the 
steam  sterilizer  with  the  dressings.  The  preliminary 
washing  with  soap  and  water  is  not  to  be  neglected. 
Silk  should  not  be  wound  on  glass  with  sharp  corners. 


PREPARATION  OF  DRESSINGS 


439 


If  sterilized  and  kept,  it  deteriorates  after  a time,  no 
matter  what  solution  is  used  as  a preservative. 

Linen  Suture  Yarn.  -This  is  occasionally  used,  and  is 
sterilized  like  silk. 

Linen  Bobbin  for  Tying  the  Cord. — Ordinary  linen 
bobbin  J-inch  wide  is  the  best  and  cheapest  material 
for  tying  the  umbilical  cord.  It  is  cut  into  lengths  of 
15  inches,  washed  with  soap  and  water,  wrapped  in 
gauze,  boiled  in  1 per  cent,  lysol  solution,  and  then  kept 


Fig.  218. — Nickel-plated  reel  on  which  the  douche-can  tube  is  sterilized,  to 
prevent  kinking. 


in  glass-stoppered  bottles  dry  or  in  alcohol.  In  private 
practice  two  lengths  are  boiled  with  the  scissors  and  kept 
in  1 per  cent,  lysol  solution  until  needed  for  tying  the 
cord. 

Basins,  pitchers,  douche-cans,  bed-pans,  etc., 
used  during  a labor  are  all  to  be  sterilized.  In  private 
practice  they  are  boiled  for  thirty  minutes  in  the  wash- 
boiler  with  the  cover  on,  and  then  wrapped  in  sterile 
pillow-slips  If  basins  are  required  in  a hurry,  one 
granite  basin  may  be  inverted  over  another,  water  placed 


440 


APPENDIX 


in  the  lower,  and  boiled  for  twenty  minutes.  China 
bowls  and  pitchers  may  be  scrubbed  with  Sapolio,  scalded 
with  boiling  water,  and  rinsed  with  2 per  cent,  lysol  solu- 
tion. If  there  is  time,  however,  all  the  utensils  should 
be  boiled.  In  hospitals  they  are  wrapped  in  special 
holders  and  sterilized  in  the  steam  sterilizer. 

Rubber  tubing  when  sterilized  is  liable  to  kink  at  the 
bends  and  prove  useless  when  most  urgently  needed. 
To  avoid  this  it  should  be  rolled  on  a spool  (Fig.  218). 

Douche-bags  of  rubber  are  first  washed  out  with  table 
salt  and  water,  using  much  friction  to  rid  the  interior  of 
the  sulphur  and  dust,  then  filled  with  gauze,  and  steamed 
or  boiled.  Kelly  pads  are  not  boiled,  but  scrubbed  with 
soap  and  water,  and  then  with  strong  bichlorid  or  lysol 
solution. 

Gowns,  aprons,  leggings,  towels,  sheets,  and 
pillow-slips  for  use  in  the  confinement  room  are 
wrapped  in  towels  or  special  holders,  pinned  securely, 
labeled  distinctly,  and  sterilized  by  steam  for  forty-five 
minutes.  They  are  dried  in  the  sterilizer  and  placed  in 
a clean  box  or  closet. 

Tables,  chairs,  bed,  and  other  furniture  in  the 

confinement  room  are  washed  with  a soft  cloth  and 
soap  and  water,  then  with  1 : 1000  bichlorid  or  3 per 
cent,  carbolic  acid  solution.  In  hospitals,  where  pus  is 
present,  this  sterilization  must  be  particularly  thorough, 
and  in  all  instances  the  tables  are  covered  with  several 
layers  of  sterile  towels  before  operations,  so  that  sharp- 
pointed  needles  may  not  pierce  through. 

Sterilising  Apartments. — After  infectious  cases 
the  room  occupied  by  the  patient  is  to  be  disinfected.  A 
simple  and  very  efficient  method  is  the  following:  The 
room  is  allowed  to  air  thoroughly,  all  the  windows  being 
opened,  the  bedding  scattered  on  chairs,  closet  doors  left 
ajar,  and  bureau  drawers  drawn  out.  Then  the  room  is 


PREPARATION  OF  SOLUTIONS 


44I 


tightly  closed,  the  cracks,  flues,  and  doors  being  sealed 
with  paper.  It  is  allowed  to  warm  up  thoroughly. 

Formaldehyd  vapor  is  generated  as  follows: 

A 2 -quart  milk  pail  is  wrapped  in  a piece  of  asbestos 
paper  and  set  inside  a papier-mache  water  pail,  dry.  For 
a room  1 5 feet  square  5 ounces  of  potassium  permangan- 
ate are  put  in  the  tin  pail.  When  everything  is  ready 
the  nurse  places  the  apparatus  in  the  center  of  the 
room  to  be  sterilized,  then  pours  20  ounces  of  formalin 
on  the  potash,  and,  holding  her  breath,  beats  a hasty 
retreat,  closing  and  sealing  the  door  behind  her. 

After  twelve  hours  the  room  is  widely  opened  and 
allowed  to  air  thoroughly  for  two  or  three  days  if  pos- 
sible. If  it  is  desired  to  dissipate  the  fumes  of  formalin 
quickly,  ammonia  may  be  spread  around.  The  ceiling, 
floor,  walls,  and  furniture  are  now  washed  with  soap  and 
water  and  new  linen  put  on  the  bed. 

Formaldehyd  lamps  are  sometimes  used  for  fumi- 
gating, but  they  are  not  more  efficient  than  the  method 
described,  which  is  recommended  by  the  Illinois  State 
Board  of  Health.  Sulphur  is  seldom  used  now  for 
fumigation.  It  ruins  household  articles,  while  formalin 
does  not.  In  my  opinion,  the  washing  and  airing  of 
the  room  do  more  good  than  the  fumigation. 

PREPARATION  OF  SOLUTIONS 

Physicians  differ  widely  in  their  choice  of  antiseptic 
solutions,  and  the  nurse  will  do  best  if  she  becomes 
thoroughly  acquainted  with  the  desires  of  her  physician 
in  this  regard. 

Sterile  Water. — In  hospitals  this  is  prepared  in  the 
large  sterilizers,  being  filtered  before  being  boiled  under 
pressure  by  steam  or  gas  In  private  homes  the  nurse 
should  scrub  the  wash-boiler  thoroughly  with  sand- 
soap,  rinse  it,  and  boil  about  8 gallons  of  water  for 


442 


APPENDIX 


forty  minutes,  setting  it  to  cool,  well  covered  up.  In 
country  practice  the  water  should  be  carefully  strained 
through  cotton,  as  it  often  contains  foreign  matter,  some- 
times living.  A dipper  should  be  boiled  and  kept, 
wrapped  in  a sterile  pillow-slip,  for  ladling  purposes, 
Hot  sterile  water  may  be  taken  from  the  tea-kettle, 
which  should  always  be  kept  full  and  boiling  on  the  stove. 
In  flats  or  apartments  in  cities  the  nurse  should  remember 
that  between  i and  5 A.  m.  the  heat  goes  down  and  the 
hot- water  supply  may  fail.  Even  in  cities  with  a known 
good  water-supply  antiseptic  solutions  should  always 
be  made  with  previously  sterilized  water.  One  should 
not  trust  the  antiseptic  (bichlorid,  lysol,  creolin)  to 
disinfect  the  water.  An  epidemic  of  tetanus  is  said  to 
have  resulted  in  a hospital  where  such  trust  was  imposed 
in  creolin.  In  all  cases,  therefore,  where  possible,  boiled 
water  should  be  employed. 

Bichlorid  of  Mercury  Solutions. — In  private  prac- 
tice the  nurse  will  use  tablets,  dissolving  them  in  hot 
water  and  adding  cool  to  bring  up  the  required  dilution. 
Strengths  of  1 : 1000  and  1 : 1500  are  usually  employed. 
Too  much  caution  cannot  be  enjoined  to  exercise  care 
to  avoid  poisoning  with  bichlorid.  In  making  up  stock 
solutions  of  bichlorid,  the  powder  or  tablets  should  be 
completely  dissolved  in  boiling  water  and  the  solution 
filtered  through  cotton.  No  bits  of  undissolved  poison 
should  be  left  in  the  bottle. 

When  used  for  douches,  the  solution  must  be  injected 
under  low  pressure  and  a douche  of  sterile  water  given 
afterward.  In  anemic  women  or  in  cases  of  kidney  or 
intestinal  disease,  this  poison  must  be  used  only  with  the 
greatest  circumspection.  Some  physicians  have  dis- 
carded it  entirely;  the  author  uses  it  very  little. 

Sublamin  is  a new  mercurial  antiseptic,  said  to  be  as 
strongly  bactericidal  as  bichlorid,  but  less  toxic  to  the 


PREPARATION  OF  SOLUTIONS 


443 


patient  and  less  irritating  to  the  hands,  even  when  used  in 
concentration. 

Carbolic  Acid  Solution.  -The  pure  crystals  are 
mixed  with  5 per  cent,  of  alcohol,  or  the  95  per  cent, 
acid  may  be  purchased.  To  make  a 5 per  cent,  solu- 
tion, the  required  amount  is  dissolved  in  boiling  water 
with  constant  and  vigorous  stirring.  No  acid  should 
form  in  globules  in  the  bottle.  After  the  acid  is  all  dis- 
solved and  the  solution  cooled,  it  is  filtered  through  cot- 
ton in  a glass  funnel.  To  make  1 gallon  of  5 per  cent, 
carbolic  acid  solution  6j  ounces  of  the  95  per  cent,  solu- 
tion are  needed. 

Lysol  Solution. — Lysol  is  a proprietary  antiseptic 
containing  50  per  cent,  of  kresol,  or  cresylic  acid  and 
tincture  of  green  soap  Liquor  cresolis  compositus  is 
the  official  name  for  the  preparation,  which  any  chemist 
can  prepare.  Only  for  brevity  is  the  proprietary  name 
used  in  the  text.  It  is  employed  in  1,  ij,  and  2 per 
cent,  solutions.  In  hospitals  it  is  made  up,  as  carbolic  is, 
in  5 per  cent,  solution  (6j  ounces  to  the  gallon),  and 
diluted  with  sterile  water  as  needed.  In  private  prac- 
tice the  solutions  are  made  from  the  pure  drug : 3 drams 
to  1 quart  of  water  make  a 1 per  cent,  solution.  The 
nurse  should  always  measure  these  drugs  and  not  trust 
to  guesswork. 

Formalin  Solution. — For  douches,  30  drops  of 
fresh  formalin  are  mixed  with  1 pint  of  sterile  water;  for 
the  hands,  1 dram  to  1 pint. 

Chinosol. — This  drug  belongs  to  a rather  large  class 
of  proprietary  antiseptics.  It  is  not  much  employed.  It 
is  a light-yellow  powder  and  is  dissolved  in  water, 
strengths  of  from  1 : 2000  to  1 : 500  being  used. 

Creolin  is  also  used,  like  lysol. 

Salt  Solution. — For  use  as  a wash  or  douche,  saline 
solution  is  prepared  by  adding  1 dram  of  pure  sterilized 


444 


APPENDIX 


table-salt  to  i pint  of  water.  When  used  for  hypo- 
dermoclysis  or  intravenous  injection,  the  solution  is  pre- 
pared with  boiling  water  and  cooled  down  to  the  tem- 
perature desired. 

A convenient  way  to  sterilize  salt  is  to  fill  2 -dram 
vials,  cork  securely,  and  sterilize  daily  for  three  days,  one 
hour  each  day.  A 2 -dram  vial  contains  just  enough 
salt  to  make  1 quart  of  0.6  per  cent,  solution.  If  the 
solution  must  be  made  in  the  absence  of  prepared  salt, 
the  boiling  must  be  done  after  the  salt  is  dissolved.  (See 
p.  225.)  Salt  solution  should  be  made  fresh,  just  before 
injection.  It  does  not  keep  well. 

Boric  Acid  Solution.  -Boric  or  boracic  acid  dis- 
solves in  water  only  to  4 per  cent.,  and  this  is  the  strength 
usually  employed.  Two  handfuls  of  the  crystals  are 
placed  in  a gallon  bottle  and  boiling  water  poured  in. 
The  bottle  is  shaken  vigorously  until  all  the  crystals  are 
dissolved;  then  it  is  set  in  a cold  place.  When  the  ex- 
cess of  boric  acid  has  crystallized  out,  the  clear  solution 
may  be  decanted  from  the  top  into  a separate  bottle. 
This  is  better  than  to  use  the  bottle  with  the  crystals  at 
the  bottom,  as  they  often  are  poured  out  when  not 
wanted. 


THE  OBSTETRIC  NURSE 

The  author  wishes  that  more  nurses  would  prepare 
themselves  for  obstetric  work  and  adopt  it  as  a specialty. 
True,  it  is  hard,  but  a woman  in  good  health,  who  knows 
how  to  manage  things,  can  systematize  her  duties  so  that 
she  will  get  along  very  comfortably.  If,  in  addition,  the 
nurse  will  insist  on  a proper  amount  of  sleep  and  oppor- 
tunity for  outdoor  recreation  being  afforded  her,  she  will 
enjoy  long  years  of  usefulness  in  this  fascinating  branch 
of  medicine.  Nurses  often  take  too  little  rest  and  do  not 
go  out  at  all  during  the  first  week.  In  well-to-do  fam- 


THE  OBSTETRIC  NURSE 


445 


ilies  the  nurse  should  be  relieved  at  night  by  another,  and 
in  those  less  fortunate  some  one  will  be  accessible  for 
relief  of  the  nurse  by  day.  The  nurse  must  not  think 
this  is  selfish — on  the  contrary,  she  will  do  better  work 
for  both  mother  and  babe  if  she  is  well  and  strong. 
Obstetric  nurses  often  form  most  intimate  and  pleasant 
friendships  with  their  patients,  and  they  find  they  have 
a personal  interest  and  satisfaction  in  seeing  the  child 
grow  and  develop.  This  alone  should  attract  to  this 
specialty  the  best  women  in  the  profession.  To  do  good 
work,  the  nurse  should  be  well  prepared,  and  she  should 
have  her  affairs  so  arranged  that  she  is  accessible  at  all 
times  and  ready  for  all  emergencies. 

She  should  have  her  satchel  packed  at  all  times  when 
awaiting  a call.  She  should  read  up  her  cases  and  do 
some  postgraduate  work  occasionally  to  save  herself 
from  rustiness.  She  should  take  with  her  to  the  obstetric 
case  a book  on  obstetric  nursing  and  consult  it  when 
anything  unusual  arises. 

List  of  Articles  Needed  by  the  Obstetric  Nurse 

One  hypodermic  syringe  and  needles  in  working  order. 

Two  tested  thermometers,  one  for  mother  and  one  for 
babe. 

One  razor,  safety  pattern. 

One  pair  surgical  scissors. 

One  pair  tissue  forceps. 

One  long  dressing  forceps  for  use  during  labor  in  hand- 
ling sterile  things  (Fig.  219). 

One  pair  rubber  gloves. 

One  rectal  tube. 

One  sterile  douche-bag  or  can. 

One  portable  sterilizer.  (See  Figs.  211,  212.) 

One  white  operating  gown. 


446 


APPENDIX 


It  is  better  if  the  patient  provides  her  own  rubber 
goods,  but  in  country  practice  the  nurse  may  need  them. 

Some  nurses  find  a Kelly  pad 
useful,  but  just  as  good  a 
pad  may  be  made  with  news- 
papers. 

The  Nurse's  Dress. - 

This  should  always  be  of 
wash  material,  of  a quiet, 
restful  color,  and  should  not 
be  worn  in  the  street.  This 
is  neither  good  taste  nor 
aseptic.  The  sleeves  should 
be  made  so  that  they  may 
be  rolled  up  above  the  elbow, 
and  stiff  cuffs  should  not  be 
worn.  They  rub  into  the  in- 
fant’s eyes  when  the  child  is 
“changed”  and  may  injure 
them.  It  might  be  added 
that  the  nurse  should  always 
appear  neat  and  clean  while 
on  duty.  During  the  night 
the  nurse  is  so  frequently 
disturbed  that  some  form  of 
wrapper  should  be  provided. 
Except  in  rare  instances  the 
nurse  should  never  try  to 
rest  in  her  uniform. 
Deportment.  -A  discus- 

Fig.  219— Nurse’s  dressing  sion  of  this  point  is  not  needed 
forceps  in  tall  bottle  of  lysol  jn  tbis  book  but  a few  bjts  0f 
solution. 

advice  may  not  be  out  of  place. 
Never  forget  the  dignity  of  the  profession  of  nurs- 
ing; at  the  same  time,  always  remember  that  even 


THE  OBSTETRIC  NURSE 


447 


menial  duties  are  compatible  with  it  and  even  may  be 
demanded. 

The  rules  of  asepsis  must  never  be  neglected  or  relaxed 
in  severity,  even  if  the  physician  does  not  practice  them 
or  if  the  circumstances  are  difficult  to  control.  The 
keenest  and  most  constant  attention  to  the  details  of 
asepsis  alone  will  guarantee  the  puerperal  woman  that 
safety  she  so  richly  deserves. 

The  lying-in  chamber  should  always  be  neat,  temper- 
ate, and  inviting,  and  the  disturbing  elements  of  the 
world  outside  of  it  should  never  enter. 

The  nurse  should,  under  no  circumstances,  allow  dis- 
agreements to  arise  between  herself  and  the  servants,  and 
when  the  mother  of  the  house  is  ill  she  should  aid  as 
much  as  possible  in  the  conduct  of  the  household  affairs. 
She  should  increase  the  duties  of  the  family  and  the 
servants  as  little  as  possible. 

The  nurse  should  never  gossip  about  her  cases. 
Family  secrets  are  too  sacred  to  be  even  hinted  at  or  to 
be  referred  to  without  names.  He  who  tells  even  the 
smallest  part  of  a secret  loses  his  hold  on  the  rest.  People 
can  often  draw  inferences  which  render  the  information 
direct.  This  bit  of  advice  cannot  be  too  deeply  im- 
pressed. 

The  nurse — and  the  doctor  too — must  abstain  from  the 
relation  of  bad  cases  or  wonderful  operations,  etc.,  be- 
cause the  patient  easily  takes  alarm  and  will  imagine 
herself  to  be  singled  out  for  each  accident  related.  The 
nurse  must  allow  no  complication  to  disturb  the  even- 
ness of  her  mind  and  action,  and  if  the  doctor  is  to 
be  called  for  some  complication,  the  patient  must  not 
know  it. 

The  nurse  should  not  allow  the  infant  to  acquire  bad 
habits,  such  as  sucking  the  fingers,  sucking  an  empty 
rubber  nipple,  water-tippling,  peppermint-  and  sugar- 


APPENDIX 


448 

water-tippling,  or  even  the  whisky  habit,  or  lying  with 
its  mother  or  other  person.  By  gentle  persistence  the 
nurse  may  engender  good  habits  of  living  at  a very 
tender  age,  for  which  the  individual  may  be  grateful  all 
his  days. 

VENEREAL  DISEASES 

Unfortunately,  these  affections  are  not  uncommon  in 
obstetric  practice,  although  usually  we  see  the  effects 
only,  not  the  disease  in  its  florid  stages. 

Gonorrhea.-  This  is  an  inflammation  of  the  urethra 
and  vulva  produced  by  the  gonococcus  of  Neisser.  It 
affects  the  pelvic  organs  slowly,  one  after  the  other,  and 
causes  chronic  inflammatory  changes  of  permanent  char- 
acter in  them.  Sterility  from  tubal  disease  or  pelvic 
abscess  may  result,  and  if  pregnancy  supervenes,  puer- 
peral peritonitis  may  be  the  final  outcome. 

If  a child  is  born  before  the  disease  is  cured,  the  gon- 
orrheal germ  may  obtain  access  to  the  eyes  and  cause 
an  inflammation  resulting  in  blindness.  (See  p.  347.) 
The  discharges  from  a gonorrheal  case  are  highly  in- 
fectious. The  woman  may  infect  her  own  eyes,  she  may 
carry  the  infection  to  others,  and  cases  are  known  wdiere 
infected  towels  caused  epidemics  of  gonorrheal  vulvitis 
in  schools  for  girls. 

Thus  the  nurse  may  appreciate  the  importance  of  treat- 
ing a case  of  gonorrhea  as  she  wrould  the  other  infectious 
diseases. 

The  symptoms  of  pelvic  gonorrhea  are  pain,  smarting 
on  urination,  pain  and  soreness  in  the  pelvis,  discharge  of 
greenish-yellow  pus,  slight  febrile  movements,  and,  later, 
the  symptoms  of  disease  of  the  organ  most  affected,  as 
pyosalpinx  or  peritonitis. 

During  pregnancy  the  disease  aggravates,  the  discharge 
being  very  profuse  and  often  fetid  and  irritating.  Warty 


VENEREAL  DISEASES 


449 


growths  may  appear  on  the  genitals,  and  an  eczema 
intertrigo  develop  there. 

Treatment.  The  physician  will  order  medicines  to 
keep  the  urine  in  an  antiseptic  condition.  Douches  of 
various  antiseptics  may  be  ordered,  the  vulva  and  vagina 
may  be  painted  with  iodin,  nitrate  of  silver,  etc.,  or  tam- 
pons of  ichthyol  inserted.  Iodoform  gauze  packing  is 
occasionally  employed.  It  is  wisest  to  get  the  disease 
well  on  the  road  to  cure  before  the  child  is  born,  to  avoid 
ophthalmia  neonatorum  and  puerperal  peritonitis. 

During  labor  the  vagina  may  have  to  be  douched  with 
lysol  solution,  and  after  the  infant  is  born  exceedingly 
rigorous  precautions  are  observed  to  prevent  any  infec- 
tion gaining  access  to  the  eyes. 

Syphilis  or  “ Specific  Disease.” — The  latter  term 
is  used  so  that  the  laity  may  not  understand  the  harsh 
meaning  of  the  diagnosis.  While  gonorrhea  is  usually  a 
local  affection,  syphilis  is  a blood  disease,  becoming  at 
once  a constitutional  taint  which  is  almost  ineradicable, 
and  is  transmissible  even  to  the  third  generation. 

There  are  three  stages  in  the  disease:  The  first  stage 
is  the  primary  sore  or  the  point  of  entrance  of  the  infec- 
tion. This  is  a hard  ulcer  and  may  occur  on  the  vulva, 
in  the  vagina,  or  on  any  part  of  the  body,  as  the  lip,  the 
tonsil,  or  the  hand,  as  not  infrequently  happens  to  phys- 
icians in  their  gynecologic  examinations.  Syphilis  is  not 
always  venereal  in  origin.  Lues  is  another  name  for 
syphilis. 

The  second  stage  begins  six  to  ten  weeks  after  the  sore 
appears,  and  is  evidenced  by  a rose-red,  fading  to  copper 
colored,  general  eruption,  headache,  falling  hair,  pains  in 
the  bones,  and  sore  throat.  There  are  superficial  ulcers 
in  the  mouth  and  around  the  vulva  and  anus.  In  these 
two  stages  the  disease  is  highly  infectious. 

The  third  or  tertiary  stage  occurs  later  in  life,  perhaps 
29 


450 


APPENDIX 


after  many  years,  and  shows  the  effects  of  the  disease 
in  the  bones,  blood-vessels,  vital  organs,  and  nervous 
system. 

If  a man  marries  while  in  the  first  or  second  stages,  he 
transmits  the  affection  to  his  wife  and  to  the  offspring. 
If  the  disease  has  no  external  signs — is  latent — he  trans- 
mits the  poison  to  the  offspring,  the  mother  being  in- 
fected from  the  child.  In  the  former  case,  abortion 
or  premature  labor  usually  terminates  the  pregnancy. 
In  the  latter  case,  a dead  and  macerated  or  a live  but 
syphilitic  infant  is  born. 

Signs  of  syphilis  in  the  newborn  child  are:  a general 
skin  eruption  of  rose  spots;  blebs  on  the  soles  and  palms; 
snuffles;  cracks  and  superficial  ulcers  around  the  anus 
and  mouth;  marasmus,  and  the  Wassermann  blood  test. 

Should  a nurse  notice  the  symptoms  mentioned  in 
either  the  mother  or  child,  the  physician  must  be  noti- 
fied. 

Prevention  of  Contagion.  —The  syphilitic  patient 
must  have  her  own  knife,  fork,  dishes,  etc.  Discharges 
are  collected  in  antiseptic  dressings,  which  are  burned. 
The  nurse  must  care  for  her  own  hands  with  the  utmost 
regard,  using  rubber  gloves  during  necessary  contact 
with  infected  parts,  as  sore  mouth  and  ulcerated  geni- 
tals. The  same  precautions  are  to  be  observed  in  hand- 
ling a syphilitic  infant.  None  but  the  mother  will  be 
allowed  to  nurse  a syphilitic  child. 

Treatment.  During  pregnancy  the  disease  becomes 
more  virulent,  and  at  all  times  it  requires  vigorous  treat- 
ment. Mercurial  baths,  mercurial  inunctions,  hypo- 
dermic injections  of  mercury,  salvarsan  (“606”),  internal 
administration  of  mercury,  are  all  employed.  Iodid  of 
potassium  is  given  later.  As  these  drugs  are  given  in 
large  and  increasing  doses,  the  nurse  will  watch  for 
mercurialization  (salivation,  fetid  breath,  sore  mouth, 


VENEREAL  DISEASES 


451 


loosening  of  the  teeth,  etc.),  iodism  (frontal  headache, 
coryza,  stiffness  in  throat,  pustular  eruption  on  the 
face  and  body),  and  arsenical  poisoning  (nausea,  vomit- 
ing, diarrhea,  prostration,  edema).  Tonic  medicines  are 
also  given,  as  a severe  form  of  anemia  often  develops. 

The  treatment  of  a syphilitic  child  is  the  same  in  prin- 
ciple as  that  of  the  adult. 

General  Consideration  of  Venereal  Disease. 

A nurse  must  never  let  the  patient  know  that  she  has 
discovered  such  an  affection. 

It  must  not  be  thought  that  because  a patient  has 
venereal  disease  it  must  have  been  acquired  in  illicit 
relations.  Physicians  and  nurses  have  acquired  syphilis 
in  the  course  of  their  work.  Men  have  acquired  it  in  the 
barber’s  chair;  washwomen,  from  washing  infected  linen; 
patients  in  the  dentist’s  chair  or  under  operation,  from  in- 
fected instruments.  A physician,  using  a eustachian 
catheter,  infected  35  patients  with  syphilis! 

These  same  possibilities  exist  with  gonorrhea.  Guarded 
speech,  therefore,  is' obligatory  on  the  nurse,  as  scandal 
is  easily  started  and  endless  domestic  woe  may  be  inaug- 
urated by  the  nurse  dropping  the  merest  hint  regarding 
the  nature  of  the  malady.  If  she  is  questioned  regard- 
ing the  manifestations  of  disease,  she  should  quietly  but 
firmly  refer  the  inquiry  to  the  physician.  Nor  may  she 
speak  of  the  disease  or  of  its  symptoms  to  any  of  her 
friends  or  other  physicians,  as  they  may  recognize  the 
description  and  connect  it  with  the  patient. 

“He  who  tells  even  the  smallest  part  of  a secret  loses 
his  hold  on  the  rest.” 


452 


APPENDIX 


DIETARY1 

LIST  OF  DIETS 

Absolute  Milk  Diet.  Milk,  whey,  matzoon,  kou- 
miss, buttermilk,  junket,  water.  Three  quarts  of  milk 
daily  are  given,  a glassful  every  two  hours. 

I/iquid  Diet.  -Water,  milk,  matzoon,  koumiss,junket, 
buttermilk,  whey,  tea,  coffee,  toast-water,  rice-water, 
egg-water,  lemonade,  broths,  beef-tea,  beef-juice,  oyster- 
stew  minus  oysters. 

Semisolid  Diet.  -All  the  above  plus  eggnog,  milk- 
toast,  cereal  foods  (boiled),  ice-cream,  corn-starch  pud- 
ding, blanc-mange,  soft-boiled  eggs,  scraped  beef,  cream 
soups,  purees  and  soups  thickened  with  rice,  barley,  or 
farina. 

Diet  for  the  Prevention  of  Overgrowth  of  the 

Child. — This  diet  must  not  be  prescribed  by  the  nurse, 
as  it  is  the  physician’s  province.  It  is  inserted  here  for 
the  sake  of  completion.  Prochownik  arranged  it,  and 
claims  that  the  women  who  follow  it  out  consistently 
have  small  but  perfectly  developed  children.  The 
author’s  results  do  not  fully  justify  this  claim.  Fred- 
erick the  Great  recommended  his  niece,  the  Princess  of 
Orania,  not  to  overnourish  her  child  during  pregnancy, 
and  the  notion  is  widespread  that  the  amount  of  food 
partaken  by  the  mother  during  pregnancy  affects  the  size 
of  the  child. 

PROCHOWNIK’S  DIET 

Breakfast. — Small  cup  of  coffee;  two  slices  of  toast  (i 
ounce) . 

Dinner. — Small  piece  of  meat  or  fish  or  an  egg,  a little 
sauce,  a vegetable  prepared  with  fat,  lettuce,  a small 
piece  of  cheese. 

1This  section  was  written  largely  by  Mrs.  E.  E.  Koch. 


RECIPES 


453 


Supper. — The  same,  with  a few  slices  of  bread  and 
butter  and  a little  milk. 

Water,  soup,  potatoes,  pastries,  sugar,  and  beer  are 
forbidden.  About  i pint  of  water  daily  is  drunk.  The 
diet  should  be  adhered  to  during  the  last  ten  or  twelve 
weeks,  always,  of  course,  under  medical  control. 

RECIPES1 

Albumin  or  Egg- water. — Stir  white  of  one  egg  into 
a pint  of  water  ice  cold.  Do  not  beat  or  shake.  Sugar, 
salt,  or  powdered  cinnamon  to  taste. 

Barley-water.  -Wash  2 ounces  (wineglassful)  of 
pearl  barley  with  cold  water.  Boil  five  minutes  in  fresh 
water.  Decant  water.  Pour  on  2 quarts  of  boiling 
water;  boil  down  to  1 quart.  Flavor  with  thinly  cut 
lemon-rind,  add  sugar  or  cinnamon  to  taste;  strain. 

If  the  mixture  is  allowed  to  boil  down  to  1 pint, 
strained,  put  on  ice,  a good  barley-jelly  results. 

Beef-tea.  -Free  1 pound  of  lean  beef  from  fat,  ten- 
don, cartilage,  bone,  and  vessels;  chop  fine,  put  into  1 
pint  of  cold  water  to  digest  two  hours.  Simmer  on 
range  or  stove  three  hours,  but  do  not  boil.  Make  up 
for  water  lost  by  adding  cold  water,  so  that  1 pint  of 
beef-tea  represents  1 pound  of  beef.  Strain  through 
cheese-cloth  without  pressure.  Should  be  clear. 

Beef-juice.— Cut  a thin,  juicy  steak  into  pieces  i| 
inches  square;  brown  separately  one  and  one-half  min- 
utes on  each  side  over  a hot  fire ; squeeze  in  a hot  lemon- 
squeezer  or  meat-press;  flavor  with  salt  and  pepper. 
May  add  to  milk  or  pour  on  toast. 

Beef-tea  with  Acid.  One  and  a half  pounds  of 
beef  (round)  cut  in  small  pieces;  same  quantity  of  ice, 
broken  small.  Let  stand  in  deep  vessel  twelve  hours. 
Strain  thoroughly  and  forcibly  through  coarse  towel. 

1 Largely  from  Thomas’  Dietary. 


454 


APPENDIX 


Boil  quickly  ten  minutes  in  porcelain  vessel.  Let  cool. 
Add  \ teaspoonful  of  acid  (dilute  phosphoric  acid)  or 
acid  phosphate  to  the  pint. 

Cereal  Extract.  -Take  2 soupspoonfuls  each  of  corn, 
barley,  oats,  rye,  maize,  and  bran;  boil  in  4 quarts  of 
water  three  hours;  allow  to  cool  and  then  strain.  If 
necessary,  add  enough  water  to  make  1 quart.  A pal- 
atable yellowish  fluid  is  obtained,  which  may  be  improved 
by  the  addition  of  milk  or  powdered  cinnamon  for 
children. 

Chicken  Broth.  -Skin  and  chop  fine  a small  chicken 
or  half  a large  fowl;  boil  it,  bones  and  all,  with  a blade 
of  mace,  a sprig  of  parsley,  a tablespoonful  of  rice,  and 
a crust  of  bread  in  1 quart  of  water  for  an  hour,  skim- 
ming it  from  time  to  time.  Strain  through  soup- 
strainer. 

Clam  Broth. — Wash  thoroughly  6 large  clams  in 
shell;  put  in  kettle  with  1 cup  of  water;  bring  to  boil 
and  keep  there  one  minute;  the  shells  open,  the  water 
takes  up  the  proper  quantity  of  juice,  and  the  broth  is 
ready  to  pour  off  and  serve  hot. 

Champagne  Whey.-  Boil  J pint  of  milk;  strain 
through  cheese-cloth.  Add  wineglassful  of  champagne. 

Egg  Lemonade.  -Beat  1 egg  with  1 tablespoonful 
of  sugar  until  very  light;  stir  in  3 tablespoonfuls  of  cold 
water  and  juice  of  small  lemon;  fill  glass  with  pounded 
ice,  shake  in  milk-shaker  for  fully  two  minutes,  pour  in 
clean  glass.  Should  be  drunk  through  straw. 

Eggnog. — Scald  some  new  milk  by  putting  it,  con- 
tained in  a jug,  into  saucepan  of  boiling  water,  but  do 
not  allow  it  to  boil.  When  cold,  beat  fresh  egg  with  a 
fork  in  a tumbler  with  some  sugar.  Beat  to  a froth,  add 
a dessertspoonful  of  brandy,  and  fill  tumbler  with  scalded 
milk.  Serve  cold.  May  shake  with  ice  in  milk-shaker; 
strain.  If  desired,  may  use  sherry  instead  of  brandy,  or 


RECIPES 


455 


omit  the  alcohol  entirely,  and  grate  a little  nutmeg  or 
cinnamon  in  glass. 

Flaxseed  Tea.  —Flaxseed  (whole),  i ounce;  white 
sugar,  i ounce  (heaped  tablespoonful);  licorice-root, 
| ounce  (2  small  sticks,  crushed  well);  lemon-juice, 
4 tablespoonfuls.  Pour  on  these  materials  2 pints  of 
boiling  water;  let  stand  in  a hot  place  four  hours;  strain 
off  the  liquor. 

Flour-ball.  -Take  1 pint  of  flour  and  pack  tightly  in 
small  muslin  bag;  throw  into  boiling  water  and  boil  five 
or  six  hours;  cut  off  the  outer  sodden  portion;  grate  the 
hard  core  fine;  blend  thoroughly  with  a little  milk,  and 
stir  into  boiling  milk  to  the  desired  thickness. 

Gum-arabic  Water.  -Dissolve  1 ounce  of  gum 
arabic  in  1 pint  of  boiling  water;  add  2 tablespoonfuls 
of  sugar,  a wineglassful  of  sherry,  and  juice  of  a large 
lemon;  cool  and  add  ice. 

Junket.  Heat  1 pint  of  fresh  milk  just  luke-warm; 
add  1 teaspoonful  of  essence  of  pepsin  or  half  a rennet 
tablet;  stir  enough  to  mix.  Flavor,  if  desired,  with 
sugar,  grated  nutmeg,  and  brandy.  Pour  into  custard 
cups;  let  stand  in  cool  place  until  firmly  curded. 

Koumiss. — Take  citrate  of  magnesia  bottle  with  shift- 
ing cork;  put  in  it  1 pint  of  milk,  J cake  of  Fleischmann’s 
yeast,  or  1 tablespoonful  of  fresh  lager-beer  yeast 
(brewers’),  i tablespoonful  of  white  sugar,  reduced  to 
syrup;  shake  well  and  allow  to  stand  in  refrigerator  two 
or  three  days,  when  it  may  be  used.  It  will  keep  there 
indefinitely  if  laid  on  its  side.  Much  waste  can  be 
saved  by  preparing  the  bottles  with  ordinary  corks 
wired  in  position  and  drawing  off  the  koumiss  with  a 
champagne  tap. 

Meat  Cure. — Procure  slice  of  steak  from  top  of 
round — fresh  meat  without  fat;  cut  meat  into  strips, 
removing  all  fat,  gristle,  etc.,  with  knife.  Put  meat 


456 


APPENDIX 


through  mincer  at  least  twice.  The  pulp  must  then  be 
well  beaten  in  roomy  saucepan  with  cold  water  or 
skimmed  beef-tea  to  consistence  of  cream.  The  right 
proportion  is  i teaspoonful  of  liquid  to  8 of  pulp;  add 
black  pepper  and  salt  to  taste;  stir  mince  briskly  with 
wooden  spoon  the  whole  time  it  is  cooking,  over  slow  fire 
or  on  cool  part  of  covered  range,  until  hot  through  and 
through  and  the  red  color  disappears.  This  requires 
about  one-half  hour.  When  done,  it  should  be  a soft, 
smooth,  stiff  puree  of  the  consistence  of  a thick  paste. 
Serve  hot.  Add  for  first  few  meals  the  softly  poached 
white  of  an  egg. 

Meat  Diet,  Raw.  -Scrape  pulp  from  a good  steak, 
season  to  taste,  spread  on  thin  slices  of  bread;  sear  bread 
slightly  and  serve  as  sandwich. 

Meat-extract  Ice. — Express  all  the  juice  from  i 
pound  of  fresh  beef.  Add  J pound  of  sugar,  3 teaspoon- 
fuls  of  fresh  lemon- juice  (except  in  dyspeptics),  1 table- 
spoonful of  cognac,  well  stirred  with  yolks  of  3 eggs. 
May  flavor  with  vanilla  Freeze. 

Milk  and  I£gg.  Beat  milk  with  salt  to  taste;  beat 
white  of  egg  until  stiff;  add  egg  to  milk  and  stir.  Flavor 
with  grated  nutmeg  or  cinnamon. 

Milk  Digested  with  Acid.  -Add  20  drops  of  dilute 
hydrochloric  acid  to  1 pint  of  water;  stir,  add  the  acidu- 
lated water  to  1 quart  of  fresh  milk,  stirring  as  it  is  added. 
If  the  milk  is  not  alkaline,  make  it  so  before  adding  the 
water  by  adding  lime-water  until  litmus-paper  shows 
the  proper  reaction;  boil  twenty  minutes  on  a slow  fire 
in  narrow-necked  vessel  to  prevent  too  much  evapo- 
ration. The  proportions  of  milk  and  water  may  be  modi- 
fied to  suit  the  case. 

Milk,  Peptonized:  Cold  Process.  In  a clean  quart 
bottle  put  1 peptonizing  powder  (extract  of  pancreas, 
5 grains;  bicarbonate  of  soda,  15  grains)  or  the  contents 


RECIPES 


457 


of  one  peptonizing  tube  (Fairchild);  add  i teacup  of  cold 
water;  shake;  add  i pint  of  fresh  cold  milk;  shake  the 
mixture  again.  Place  on  ice;  use  when  required  without 
subjecting  to  heat. 

W arm  Process.  — Mix  peptonizing  powder  with  water 
and  milk  as  described  above ; place  bottle  in  water  so  hot 
that  the  whole  hand  can  be  held  in  it  for  a minute  with- 
out discomfort;  keep  the  bottle  there  ten  minutes;  then 
put  on  ice  to  check  further  digestion.  Do  not  peptonize 
long  enough  to  render  milk  bitter. 

Milk-toast,  Peptonized.  -Over  2 slices  of  toast 
pour  1 gill  of  peptonized  milk  (cold  process);  let  stand 
on  back  of  stove  for  thirty  minutes.  Serve  warm,  or 
strain  and  serve  fluid  portion  alone.  Plain  light  sponge- 
cake may  be  similarly  given. 

Milk,  Sterilized. — Put  the  required  amount  of  milk 
in  clean  bottles  (if  for  infants,  each  bottle  holding  enough 
for  one  feeding) . Plug  mouths  lightly  with  rubber  stop- 
pers or  non-absorbent  cotton;  immerse  to  shoulders  in 
kettle  of  cold  water;  boil  twenty  minutes  or,  better, 
steam  thirty  minutes  in  ordinary  steamer;  push  stoppers 
in  firmly;  cool  bottles  rapidly  and  keep  in  refrigerator. 
Warm  each  bottle  just  before  using. 

Milk-shake.  -White  of  1 egg,  1 dram  of  sugar,  2 
tablespoonfuls  of  chipped  ice,  1 ounce  of  cream.  Shake 
in  milk-shaker  two  minutes.  Add  cold  milk  to  fill 
glass;  flavor  with  vanilla  or  lemon. 

Mutton  Broth.  —Lean  loin  of  mutton,  ij  pounds, 
including  bone;  water,  3 pints.  Boil  gently  until  tender, 
throwing  in  a little  salt  and  onion,  according  to  taste. 
Pour  broth  into  saucepan;  when  cold,  skim  off  fat. 
Warm  up  as  wanted. 

Nutritious  Coffee.  Dissolve  a little  isinglass  or 
gelatin  (Knox)  in  water;  put  \ ounce  of  freshly  ground 
coffee  into  saucepan  with  1 pint  of  new  milk,  which 


458 


APPENDIX 


should  be  nearly  boiling  before  the  coffee  is  added;  boil 
both  together  for  three  minutes.  Clear  it  by  pouring 
some  of  it  into  a cup  and  dashing  it  back  again ; add  the 
isinglass,  and  leave  it  to  settle  on  back  of  stove  for  a few 
minutes.  Beat  an  egg  in  a breakfast-cup  and  pour 
the  coffee  upon  it;  if  preferred,  drink  without  the  egg. 

Rice-water.  -Pick  over  and  wash  2 tablespoonfuls 
of  rice ; put  into  granite  saucepan  with  1 quart  of  boiling- 
water;  simmer  two  hours,  when  rice  should  be  softened 
and  partially  dissolved;  strain;  add  saltspoonful  of  salt; 
serve  warm  or  cold.  May  add  2 tablespoonfuls  of  sherry 
or  port. 

Rum  Punch.  -White  sugar,  2 teaspoonfuls;  1 egg, 
stirred  and  beaten;  warm  milk,  1 large  wineglassful; 
Jamaica  rum,  2 to  4 teaspoonfuls;  nutmeg. 

Toast-water.  — Toast  3 slices  of  stale  bread  to  dark 
brown,  but  do  not  burn;  put  into  a pitcher;  pour  over 
them  1 quart  of  boiling  water;  cover  closely  and  let 
stand  on  ice  until  cold ; strain.  May  add  wine  and  sugar. 

Whey.  —Boil  1 pint  of  milk  with  1 or  2 teaspoonfuls 
of  lemon-juice;  strain  in  muslin,  expressing  all  fluid  from 
the  curd.  Break  the  curd  up  first,  and  much  fat  and 
some  finely  divided  casein  will  be  expressed  with  the 
whey.  For  infants,  use  rennet  tablet  or  junket  tablet, 
J grain  to  1 pint,  and  keep  warm  ten  minutes.  If  no  fat 
is  wanted,  strain  gently  through  fine  napkin. 

Wine  Whey.  Put  2 pints  of  new  milk  in  saucepan 
and  stir  over  clear  fire  until  nearly  boiling;  then  add  1 
gill  (2  wineglassfuls)  of  sherry  and  simmer  one-quarter 
of  an  hour,  skimming  curd  as  it  rises.  Add  1 table- 
spoonful more  sherry,  and  skim  again  for  a few  minutes; 
strain  through  coarse  muslin.  May  use  2 tablespoonfuls 
of  lemon-juice  instead  of  wine. 


RECTAL  FEEDING 


459 


RECTAL  FEEDING 

General  Rules. — Cleanse  the  rectum  morning  and 
evening  with  an  enema  of  io  ounces  of  sterile  saline 
solution  (0.6  per  cent.).  Arrange  time  so  that  cleansing 
comes  one  hour  before  the  nutritive  enema.  Inject  high 
into  the  sigmoid  flexure,  using  the  soft-rubber  rectal  tube 
for  adults  and  the  soft  velvet-eye  No.  12  or  14  cath- 
eter for  children.  Use  sweet  oil  or  vaselin  as  a lubricant, 
but  not  glycerin.  Expel  all  air  from  the  tube.  Inject 
slowly  from  2 to  8 ounces  of  the  prepared  food,  warmed 
to  body  temperature.  Do  not  inject  oftener  than  once 
in  six  hours,  except  in  emergencies.  Aid  retention  of  food 
by  placing  patient  on  the  left  side,  the  hips  elevated  by  a 
pillow,  a soft  compress  retained  against  the  anus  for 
twenty  to  thirty  minutes.  If  the  rectum  becomes  irri- 
table, notify  the  physician;  he  may  prescribe  from  5 to  20 
drops  of  tincture  of  opium  with  the  nutrient  enema,  or 
the  same  amount  of  tincture,  or  J to  1 grain  of  extract 
of  opium,  one-half  hour  before  the  enema.  This  dosage 
must  not  be  often  repeated.  Apply  2 per  cent,  cocain 
solution  to  painful  hemorrhoids,  but  by  order  only. 

Salt  solution  is  often  given  postpartum  in  the  treat- 
ment of  anemia  from  severe  hemorrhage.  If  the  uterus 
and  vagina  are  tamponed,  the  lower  bowel  will  sometimes 
hold  a quart.  The  anus  should  be  supported  by  firm 
pressure  through  a folded  towel.  Later,  saline  solution 
is  administered  in  smaller  doses,  8 ounces  every  four 
hours,  or  by  the  drop  method. 

Peptonized  Milk. — In  this  case  the  milk  is  thor- 
oughly peptonized,  requiring  two  hours.  From  6 to  8 
ounces  are  injected  every  six  or  eight  hours. 

Peptonized  Milk  with  Hg’g'.  —While  peptonizing 
milk,  add  2 eggs  to  each  pint.  Peptonize  two  hours  at 
body  temperature  and  set  on  ice. 


460 


APPENDIX 


This  food  is  also  readily  absorbed — 3 eggs,  a tea- 
spoonful of  salt,  1 ounce  of  starch,  and  \ pint  of  milk. 

Digested  Beef.  —To  1 tablespoonful  of  minced  lean 
beef  add  4 tablespoonfuls  of  cold  water;  gradually  heat 
to  boiling.  Rub  through  a fine  sieve,  and,  when  luke- 
warm, add  one  peptonizing  tube  (Fairchild)  or  an  equiva- 
lent amount  of  liquid  pancreatin  (P.  D.  & Co.).  Inject 
at  once.  May  be  diluted  more  if  necessary. 

Any  combination  of  eggs,  milk,  and  meat  may  be  pep- 
tonized and  injected,  or  mixed  with  peptonizing  powder 
and  injected  at  once,  the  digestion  or  peptonization  to  go 
on  in  the  rectum. 

Liquid  peptonoids,  peptones,  somatose,  etc.,  are  some- 
times used,  but  the  author  recommends  the  freshly  pre- 
pared foods. 

Dextrin  is  sometimes  given  per  rectum.  Formula: 
Dextrin,  50;  9 to  10  per  cent,  salt  solution,  250  grams. 

Grape-sugar,  60  grams  (2  ounces),  milk,  250  c.c.  (8 
ounces),  may  be  given,  or  the  same  amount  of  corn- 
starch in  milk  or  malted  milk  plain. 

Alcohol  is  sometimes  used,  but  the  rectum  soon  be- 
comes intolerant  of  all  feeding,  and  more  harm  than  good 
is  accomplished.  Glucose  is  absorbed  in  moderate  quan- 
tities by  the  rectum,  and  also  emulsified  animal  oils. 

Under  all  methods  of  rectal  feeding  the  patient  does 
not  obtain  sufficient  calories  or  heat-units  to  maintain  a 
proper  balance  of  nutrition. 

FEEDING  THROUGH  THE  SKIN 

One  may  introduce  a small  amount  of  nourishment 
through  the  skin  by  inunctions  of  lard.  This  is  especially 
valuable  in  babies  with  wasting  diseases. 

Hypodermically,  salt  solution  may  be  injected  in  large 
quantities — up  to  2 quarts  daily — to  replace  liquid  losses 
from  profuse  diarrhea  or  constant  vomiting,  as  in  hyper- 


NASAL  FEEDING 


461 


emesis  gravidarum.  It  has  also  been  suggested  to  add 
soluble  foods  to  the  hypodermic  injection,  but  practical 
results  are  not  yet  published.  Our  attempts  are  as  yet 
experimental. 

NASAL  FEEDING 

In  unconscious  patients  it  is  sometimes  possible  to 
introduce  liquids,  food,  and  medicine  through  a tube 
passed  into  the  nose  and  thence  into  the  upper  esoph- 
agus. A stomach-tube  of  small  size  (about  No.  16, 
American  scale)  is  oiled  and  passed  gently  along  the 
floor  of  the  nose  (not  upward  toward  the  eye)  until  it 
reaches  half-way  to  the  stomach  (about  12  inches).  The 
nurse  makes  sure  that  the  tube  is  not  in  the  windpipe  by 
putting  her  ear  to  the  open  end ; if  air  rushes  in  and  out, 
the  tube  is  in  the  trachea.  It  is  taken  out  and  reinserted, 
bending  the  head  slightly  on  the  chest  while  so  doing. 
After  the  tube  is  passed  and  there  is  no  doubt  about  its 
being  in  the  esophagus,  the  liquid  is  slowly  poured  into 
the  funnel  and  the  tube  quickly  withdrawn. 

The  nurse  must  take  care  that  the  stomach  is  not  over- 
filled by  too  frequent  and  too  copious  feedings. 


GLOSSARY 


[The  American  Illustrated  Medical  Dictionary  has  been  largely  used  in  the 
preparation  of  this  glossary.  The  numbers  at  the  end  of  the  definition 
indicate  the  page  in  the  text  describing  the  subject.] 


A. 

Abactus  venter  (ab-ak'tus  ven'-  I 
ter)  [L.].  Induced  abortion. 

Abdomen  ' ab-do'men).  The  belly; 
that  portion  of  the  body  which  lies 
between  the  thorax  and  the  pelvis. 

Abdominal  ( ab-dom'in-al).  Per- 
taining to  the  abdomen.  A.  deliv- 
ery, delivery  of  the  child  through  an 
incision  in  the  abdomen ; Cesarean 
section  A.  gestation,  pregnancy  oc- 
curring outside  of  the  uterus  in  the 
free  abdominal  cavity.  A.  preg- 
nancy, same  as  Abdominal  gestation. 
A.  section,  cutting  through  the  ab- 
dominal wall  into  the  abdominal  cav- 
ity ; Cesarean  section;  celiotomy; 
laparotomy. 

Ablactation  ( ab-lak-ta'shun) . The 
weaning  of  a child ; cessation  of  the 
secretion  of  milk.  p.  326 

Abnormal  (ab-nor'mal).  Unnat- 
ural ; contrary  to  the  usual  structure 
or  condition. 

Abortifacient  (ab-or-tif-a'shent). 

1.  Causing  abortion.  2.  A drug  ca- 
pable of  producing  abortion  or  mis- 
carriage. 

Abortion  (ab-or'shun).  The  expul- 
sion of  the  fetus  during  first  28  weeks 
of  pregnancy,  or  before  it  is  viable. 
P-  55- 

Abrasion  (ab-ra'zhun).  A rub- 
bing-off of  a portion  of  skin  or  mu- 
cous membrane.  A spot  from  which 
the  skin  or  mucous  membrane  has 
been  rubbed. 

Abruptio  placentae.  Premature  ! 
detachment  of  the  normally  implanted  I 
placenta,  p.  251. 

Abscess  (ab'ses).  A collection  of 
pus  in  a cavity. 


Absorbent  (ab-sor'bent).  1.  Tak- 
ing up  by  suction.  2.  A dressing  or 
medicine  which  takes  up  moisture. 

Accouchement  (ah  - koosh  - maw') 
[Fr.] . Delivery  ; the  act  of  being  de- 
livered. A.  force  (for-sa'),  rapid  ar- 
tificial delivery.  Done  in  case  of 
placenta  prsevia  or  eclampsia. 

Accoucheur  (ah-koosh-er')  [Fr.]. 
An  obstetrician. 

Accoucheuse  (ah-koosh-ez')  [Fr.]. 
A midwife. 

Acid  (as'id).  1.  Sour;  having 
properties  opposed  to  those  of  the 
alkalis.  2.  A chemical  compound 
which  has  the  power  of  uniting  with 
an  alkali  to  form  a new  compound 
called  a salt.  A.  reaction,  the  turn- 
ing of  litmus-paper  red  ; a test  for  the 
presence  of  acids. 

Acinus  (as'in-us),  pi.,  a'cini.  1. 
Any  one  of  the  smallest  lobules  of  a 
compound  gland,  like  the  liver.  2. 
One  of  the  small  air-sacs  of  the  lungs. 

Acme  (ak'me).  The  crisis  or  criti- 
cal stage  of  a disease. 

Acrid  (ak'rid).  Pungent;  irritating. 

Acute  (ak-ut/).  1.  Sharp-pointed. 

2.  severe.  The  term  is  applied  to 
diseases  which  have  severe  symptoms 
but  are  of  short  duration. 

Adnexa  (ad-nek'sah)  [L.  pi.].  Ap- 
pendages or  adjunct  parts  ; especially 
those  of  the  uterus — the  ovaries  and 
tubes.  Uterine  a.,  the  ovaries  and 
Fallopian  tubes.  Fig.  15. 

After-birth  (after-berth).  The 
placenta,  with  the  membranes  and 
umbilical  cord.  pp.  41-46. 

After-care  (after-liar).  The  caje 
or  nursing  of  convalescents. 

After-pains  (af'ter-panz).  Pains 
due  to  the  contraction  of  the  uterus 
463 


464 


GLOSSARY 


after  the  placenta  has  been  expelled.  I 
pp.  61,  299. 

Agalactia  (ah-gal-ak'she-ah).  Ab-  1 
sence  of  the  milk  secretion,  p.321. 

Albolene  (al'bo-len).  An  oily 
white  substance  made  from  petro- 
leum. The  solid  resembles  vaselin, 
and  is  used  in  making  ointments. 
The  liquid  is  used  for  spraying  the 
nose  and  throat. 

Albuminuria  (al-bu-min-u're-ah). 
The  presence  of  albumin  in  the  urine. 

p.  86. 

Alimentation  ( al  -i  m-en-ta'shun) . 
The  act  of  taking  nourishment. 

Alkaline  (al'kal-in).  Having  the 
properties  of  an  alkali.  A.  reaction, 
the  turning  of  litmus-paper  blue. 

Alvine  (al'vin).  Pertaining  to  the 
stomach  or  bowels.  A.  dejections, 
the  feces. 

Amenorrhea  (am  - en  - or-re  'ah). 
Absence  of  the  menstrual  flow. 

Amnii,  Liquor  (am'ne-i  li'kwor). 
The  water  surrounding  the  fetus  in 
the  uterus,  p.  42. 

Amnion  (am'ne-on).  The  most 
internal  membrane  containing  the 
waters  which  surround  the  fetus  in 
the  uterus,  p.  42. 

Amniotic  (am-ne-ot'ik).  Pertain- 
ing to  the  amnion.  A.  sac,  the  mem- 
branes surrounding  the  fetus  in  the 
uterus. 

Anemia  (an-e'me-ah).  1.  De- 
ficiency in  the  quantity  or  quality  of 
the  blood:  it  may  be  general  or  local. 
2.  Deficiency  in  the  number  of  red 
blood-corpuscles. 

Anemic  (an-em'ik).  Having 
anemia. 

Anemoscope  (a-nem'o-skop).  1. 
An  instrument  to  indicate  the  direc- 
tion of  air-currents.  2.  The  little 
wheel  in  the  outlet  flue  of  an  incuba- 
tor. p.  37^. 

Anencephalus  (an-en-sef'al-us). 
A single  monster  born  without  cra- 
nium or  brain. 

Anesthesia  ' an  - es  - the  ' zhe  - ahh 
Loss  of  feeling  or  perception  ; it  may 
be  general  or  local. 

Anesthetic  Can  - es-thet  'ikh  1. 
Having  no  preception  or  sense  of 
touch.  2.  A drug  capable  of  pro- 
ducing anesthesia,  p.  120. 

Anesthetist  (an-es'thet-ist).  A per- 1 


son  skilled  in  administering  anes- 
thetics. 

Ankyloglossia  (ang-kil-o-glos'se- 
ah).  Tongue-tie.  p.  357. 

Ankylosis  ang-kil-o'sis).  Stiffen- 
ing of  joints.  A joint  which  has  be- 
come immovable. 

Annular  (an'u-lar).  In  the  form 
of  a ring. 

Anorexia  (an-o-rek'se-ah).  Loss 
of  appet.te  for  food. 

Anteflexion  (an-te-flek'shun).  A 
bending  fn  ward,  as  of  the  uterus, 

Ante  partum  (an-te  par'tum)  [L.]. 
Before  t.ie  birth  of  a child. 

Anterior  (an-te're-or).  Situated  in 
front  of. 

Anthelmintic  (an-thel-min'tik).  1. 
Destroying  worms.  2.  A remedy  for 
intestinal  worms. 

Antiseptic  (an-te-sep'tik).  Pre- 
venting sepsis,  pus-formation,  or  pu- 
trefaction. Among  the  best  common 
antiseptics  are  alcohol,  creasote,  car- 
bolic acid,  corrosive  sublimate  (bi- 
chlorid  of  mercury),  chlorin,  char- 
coal, boric  acid,  tannic  acid,  lysol. 
A.  dressing,  a surgical  dressing  con- 
taining an  antiseptic.  A.  surgery,  sur- 
gery with  proper  use  of  antiseptics. 

Anus  (a'nus)  [L.].  The  external 
open  ng  of  ihe  rectum,  pp.  31-34. 

Apathetic  (ap-a-thet'ik).  Without 
emo  ion.  Iad.fferent  to  surroundings. 

Aphthse  (af'the).  Small  whitish 
erosions  on  the  mucous  membrane 
of  the  mouth.  See  Bednars  a.  p.  334. 

Areola  (ar-e  -o'lah).  The  pig- 
mented ring  around  the  nipple. 
Secondary  a.,  a slightly  pigmented 
ring  just  outside  the  areola,  some- 
times observed  after  the  fifth  month 
of  pregnancy,  p.  36. 

Argyrol  (ar'jir-ol).  A drug;  a 
preparation  of  silver. 

Arterial  ar-te're-alV  Pertaining 
to  an  artery.  A.  blood,  the  bright  red 
blood  in  the  arteries,  which  has  been 
aerated,  or  charged  with  oxygen  in 
the  lungs.  A.  hemorrhage,  hemor- 
rhage from  an  artery. 

Artery  nr'ter-e'.  One  of  the  ves- 
sels carrying  blood  from  the  heart ; so 
called  because  the  ancients  thought 
thev  contamed  air. 

Articular  (ar-tik'u-lar).  Pertain- 
ing to  a joint. 


GLOSSARY 


465 


Articulation  (ar-tik-u-la'shun).  A 
joint ; the  junction  of  two  bones. 

Ascites  (as-si'tez).  An  accumula- 
tion of  serous  fluid  in  the  free  ab- 
dominal cavity.  Dropsy  of  the 
abdomen. 

Asepsis  (ah-sep'sis).  Without  sep- 
sis ; freedom  from  infection  ; surgical 
cleanliness. 

Aseptic  (ah-sep'tik).  In  a surgi- 
cally clean  manner. 

Asphyxia  (as-fix'e-ah).  Suspended 
animation  ; interrupted  respiration  ; 
that  state  in  which  there  is  complete 
suspension  of  the  powers  of  m.nd  and 
body.  A.  neonato  rum,  asphyxia  of 
the  new-boin.  p.  360. 

Aspirating  needle  ( as-pir-a'ting 
ne'dl,.  A hollow  needle  attached  to 
a suction  syringe  : used  for  withdraw- 
ing fluids  from  the  body. 

Assimilate  (as-sim'i-late).  To  con- 
vert food  into  chyle  and  blood ; to 
change  food  into  a substance  like 
the  living  body. 

Astringent  (as-trin'jent).  Having 
the  power  to  diminish  excessive  dis- 
charges. 

Atelectasis  (at-el-ek'tas-is).  1. 
Imperfect  expansion  of  the  lungs  at 
birth.  2.  Partial  collapse  of  the 
lungs,  p.  337. 

Atony  (at'on-e).  Lack  of  normal 
tone  or  strength. 

Atrophic  (at-rof'ik).  Not  properly 
nourished  ; showing  atrophy. 

Atrophied  (at'ro-fed).  Wasted; 
having  atrophy. 

Atrophy  (at'ro-fe).  Wasting  or 
emaciation  with  loss  of  strength,  but 
without  fever. 

Autoclave  < aw'to-klav).  A high 
pressure  steam-sterilizer. 

Autoinfection.  Infection  from 
germs  living  in  the  vagina  not  intro- 
duced from  without,  p.  283. 

Autotransfusion  ( aw"to-trans-fu'- 
zhun).  The  forcing  of  blood  into  the 
vital  parts  of  the  body  by  bandaging 
or  elevating  the  limbs. 

Avicenna  (av-i-sen'ah).  Moham- 
medan physician.  Born  980;  died  1037. 

Axilla  (nk-sil'lah).  The  arm-pit. 

Axis-traction  (ak'sis-trak'shun). 
Pulling  or  drawing  on  the  head  of  the 
child  during  delivery,  in  the  direc- 
tions normally  followed  by  the  head 
30 


during  birth — i.  e.,  in  the  axis  of  the 
pelvis.  A.-t.  forceps,  obstetric  for- 
ceps with  an  attachment  for  producing 
axis-traction,  p.  191. 

B. 

Bacteria  (bak-te're-ah)  [L.].  Plu- 
ral of  Bacterium.  Vegetable  micro- 
organism. 

Bag  of  Waters.  The  membranes 
enclosing  the  liquor  amnii  and  the 
fetus.  Sometimes  applied  to  that 
portion  of  the  membranes  which  pro- 
trude into  the  os.  p.  59. 

Ballottement  (bal-ot-maw').  The 
diagnos.s  of  pregnancy  by  pushing 
up  the  uterus  by  a finger  inserted 
into  the  vagina,  so  as  to  cause  the 
fetus  to  rise  and  fall  again  like  a 
heavy  body  in  water. 

Barnes’  bags  (barnz).  Rubber 
bags  used  to  dilate  the  cervix  uteri, 
p.  231. 

Basiotribe  (ba'se-o-trib).  An  in- 
strument for  crushing  the  base  of  the 
fe'al  skull. 

Basiotripsy  (ba ' se  - o -t  rip  - se). 
Crush. ng  the  fetal  skull  with  a basio- 
tribe. 

Baudelocque  (bo-del-ok').  A fa- 
mous French  obstetrician.  Born 
1746;  died  1810.  B.’s  diameter, 
the  external  conjugate  diameter  of 
the  pelvis,  measured  from  the  last 
lumbar  spine  behind  to  the  top  of 
the  pubic  bone  in  front. 

Bednar’s  aphthae  (bed-nars'  af'- 
the).  Shallow  ulcers  in  the  back  part 
of  the  mouth  of  the  new-born.  They 
are  caused  by  badly  shaped  rubber 
nipples,  or  by  force  in  cleansing  the 
mouth,  p.  334. 

Bimanual  (bi  - man  ' u-al).  Per- 
formed with  both  hands.  B.  palpa- 
tion, examination  of  the  pelvic  or- 
gans of  a woman  with  one  hand  on 
the  abdomen  and  two  fingers  of  the 
other  hand  in  the  vagina. 

Binder  (bin'der).  A broad  band 
passed  tightlv  around  the  abdomen 
after  childbirth,  pp.  92,  308. 

Birth  (berth).  1.  The  delivery  of 
a child.  2.  That  which  is  born.  B.- 
mark,  “ mother’s  mark  “ maternal 
mark.”  A blemish  on  the  skin  found 
at  birth,  p.  83. 


4 66 


GLOSSARY 


Bistoury  (bis'too-re).  A small 
knife  for  surgical  purposes. 

Blennorrhea  (blen-nor-re'ah).  An 
excessive  secretion  of  the  mucous 
glands  of  any  mucous  membrane. 

Borborygmus  (bor-bo-rig'mus), 
pi.,  borborygmi  [L.].  A rumbling 
noise  made  by  gases  in  the  bowels. 

Bougie  (boo-zhe')  [Fr.].  A slender 
instrument  for  introduction  into  the 
urethra,  esophagus,  uterus,  vagina,  or 
rectum. 

Breast-pump  (brest-pump).  An 
instrument  for  drawing  the  milk  out 
of  the  breast,  p.  163. 

Breech  (brech).  The  buttocks.  B. 
delivery,  labor  in  which  the  breech 
presents  and  is  delivered  first,  p.  177. 

Brim  (brim).  The  upper  edge  of 
the  pelvis ; the  inlet,  or  superior 
strait.  Figs.  1,5,9. 

C 

Calorie  (kal'o-re).  The  amount 
of  heat  which  the  combustion  of  a 
given  material  will  develop  in  raising 
one  kilogram  of  water  from  o°  to  i° 
C.  p.  402. 

Capillary  (kap'il-la-re).  1.  Re- 
sembling hair  in  size.  2.  One  of  the 
minute  blood-vessels  which  form  a 
network  between  the  minute  arteries 
and  veins. 

Caput  (ka'put),  pi.,  cap'ita  [L.]. 
The  head,  including  the  skull  and 
face.  C.  incunia'tum,  impaction  of 
the  fetal  head  during  labor.  C.  suc- 
ceda'neum,  a dropsical  swelling  on 
the  presenting  part  of  the  head  during 
labor,  due  to  lack  of  pressure  on  that 
part.  p.  356. 

Carbohydrate  (kar  -bo  -hi' drat). 
One  of  a group  of  chemical  com- 
pounds of  which  sugar,  starches,  and 
gums  are  the  most  important. 

Carbon  dioxid  (kar'bon  di-ox'id). 
Carbonic  acid  gas. 

Caries  (ka're-ez).  Decay  of  the 
bones  or  teeth. 

Carminative  (kar-min'at-iv).  A 
drug.  A remedy  for  flatulence, 
tending  to  relieve  same. 

Cartilage  (kar'til-ej).  Gristle;  a 
pearly  white,  glistening  substance 
formed  at  the  articular  surfaces  of 
bones.  Ensiform  c.,  the  cartilage 


I at  the  lower  extremity  of  the  breast- 
bone. 

Casein  (ka'se-in).  The  principal 
proteid  of  milk  and  the  basis  of  cheese. 

Caseo'sa,  Ver'nix.  The  greasy, 
whitish  substance  which  covers  the 
skin  of  the  fetus,  p.  69. 

Cast  (kast).  A model  of  a hollow 
organ,  especially  one  of  the  tubules 
of  the  kidney,  and  found  in  the  urine. 

Carminative.  A remedy  which 
aids  the  expulsion  of  gas  in  the  bowels 
or  stomach,  p.  288. 

Cathartic  ( kath-ar'tik).  1.  Purga- 
tive or  purging.  2.  A drug  that  in- 
creases evacuation  from  the  bowels. 

Catheter  (kath'et-er).  A slender 
tubular  instrument  for  withdrawing 
fluids  from  a cavity  of  the  body  or 
for  distending  a passage.  Tracheal 
C.,  a woven  catheter  used  for  aspirat- 
ing foreign  substances  from  the  wind- 
pipe of  the  child,  and  for  blowing  air 
into  the  lungs,  p.  360. 

Cauli  kawl).  A portion  of  the  am- 
niotic  membrane  which  sometimes 
covers  the  child’s  head  at  birth. 

Celiotomy  ( se-le-ot'o-me).  Ab- 
dominal section  ; laparotomy  ; open- 
ing the  abdomen. 

Cell  (sel).  1.  Any  one  of  the  minute 
| masses  of  protoplasm  of  which  organ- 
ized tissue  is  composed.  2.  One  of 
the  chambers  holding  the  fluids  of  a 
galvanic  battery.  3.  A small,  partly 
closed  space,  as  an  air-cell. 

Cellulitis  (sel-u-li'tis).  Inflamma- 
tion of  cellular  tissue ; especially 
purulent  inflammation  of  the  loose 
subcutaneous  tissue. 

Cephalhematoma  (sef"al-he-mat- 
o'mah).  A blood-tumor  occurring 
on  the  head  of  the  new-born  infant. 
P-  356. 

Cephalic  1 sef-al'ik).  Pertaining  to 
the  head.  C.  pole,  the  head  of  the 
fetus.  C.  presentation,  the  presen- 
tation of  any  part  of  the  head  of  the 
fetus  in  delivery,  p.  169. 

Cephalotomy  (sef-al-ot'o-me).  The 
operation  of  cutting  or  breaking  down 
the  fetal  head;  craniotomy. 

Cephalotribe  (sef'al-o-trib).  An 
instrument  for  crushing  the  fetal 
head. 

Cephalotripsy  (sef'al  - o - trip  - se). 
t The  operation  of  crushing  the  fetal 


GLOSSARY 


467 


skull  with  the  cephalotribe.  See 
Craniotomy. 

Cerebrospinal  (ser"e-bro-spi'nal). 
Relating  to  the  brain  and  spinal  cord. 
C.  fluid,  the  clear  fluid  in  the  ven- 
tricles of  the  brain  and  in  the  central 
canal  of  the  spinal  cord. 

Cervix  (ser'vix)  [L.].  The  neck 
or  any  neck-like  part,  especially  the 
back  part.  C.  u'teri,  the  neck  or 
narrow  lower  end  of  the  uterus. 

Cesarean  section  ( se-za're-an). 
The  operation  of  cutting  through  the 
abdominal  walls  and  through  the 
walls  of  the  uterus,  and  delivering 
the  child  through  these  incisions,  p. 
201. 

Chafe  (chaf).  1.  To  fret  and  wear 
by  rubbing.  2.  The  reddened,  irri- 
tated skin  in  the  folds  of  fat  babies, 
p.  159. 

Chloasma  (klo-az'mah).  An  affec- 
tion of  the  skin  in  which  there  are 
patches  with  a yellowish  or  brown- 
ish discoloration.  C.  gravid'arum, 
chloasma  which  occurs  during  preg- 
nancy. C.  uteri'num,  the  mask  of 
pregnancy,  p.  52,  Fig.  71. 

Chorea  (ko-re'ah).  St.  Vitus’ 
dance ; a nervous  disease  in  which 
there  are  convulsive  movements. 

Chorion  (ko're-on).  The  more  ex- 
ternal of  the  fetal  membranes. 

Chromicized  catgut  (kro'mis-izd 
kat'gut).  Catgut  treated  with  chromic 
acid.  It  is  used  for  sutures  and  liga- 
tures. 

Chronic  (kron'ik).  Long-contin- 
ued; the  opposite  of  acute. 

Cicatricial  ( sik-at-rish'al).  Relat- 
ing to  a cicatrix  or  scar. 

Cicatrix  (sik-a'trix  or  sik'at-rix), 
pi.,  cica' trices  [L.,  “scar”].  A 
scar.  The  mark  left  by  a sore  or 
wound. 

Cilia  (sil'e-ah).  The  eyelashes. 

Circulatory  (sir'ku-la-to-re).  Re- 
lating to  the  circulation.  C.  system, 
the  heart,  arteries,  veins,  and  capil- 
laries, taken  as  a whole. 

Circumcision  (ser-kum-sizh'un). 
The  removal  of  all  or  a part  of  the 
foreskin,  or  prepuce,  p.  338. 

Cleft  palate  (kleft  pal-at).  A con- 
genital split  in  the  roof  of  the  mouth, 
so  that  the  nose  and  mouth  form  one 
cavity,  p.  356. 


Climacteric  (kli-mak-ter'ik).  The 
cessation  of  menstruation  in  women. 

Clitoris  (klit ' o - ris).  A small, 
elongated,  erectile  body,  situated  at 
the  anterior  part  of  the  vulva. 

Clonic  spasms  (klon-ik).  Spasms 
in  which  the  contractions  and  relaxa- 
tions alternate,  as  in  eclampsia. 

Clyster  (klis'ter).  An  enema. 

Coagulated  (ko  - ag  ' u - lat  - ed). 
Clotted. 

Coaptation  (ko-ap-ta'shun).  The 
fitting  together  of  displaced  parts,  as 
the  ends  of  a fractured  bone. 

Collapse  (kol-laps').  1.  To  fall  in. 
2.  Extreme  depression  or  complete 
prostration  of  the  vital  powers,  with 
failure  of  circulation. 

Collyrium  ( kol-ir'e-um).  An  eye- 
| wash  or  salve  for  the  eyes. 

Colostrum  (ko-los'trum)  [L.].  The 
first  fluid  secreted  by  the  mammary 
glands  after  delivery.  It  contains  less 
casein  and  more  albumin  than  the  or- 
dinary milk,  as  well  as  numerous  fatty 
globules.  C. -corpuscles,  the  granu- 
lar cells  found  in  colostrum,  p.  65. 

Colpeurynter  ( kol'pu-rin-ter).  A 
I dilatable  bag  used  to  distend  the 
vagina,  p.  231. 

Colpeurysis  (kol-pu'ris-is).  Dila- 
tation of  the  vagina  by  means  of  the 
colpeurynter. 

Coma  (ko'mah)  [L.].  Profound 
stupor  or  drowsiness  occurring  in  the 
course  of  certain  diseases,  as  eclamp- 
sia, or  after  severe  injury. 

Comatose  (ko 'mat  - os).  Affected 
with  coma. 

Comedo  (kom-e'do),  pi.,  comedo'  nes. 
“ Black-heads.”  The  dried  plugs  of 
sebaceous  matter  sometimes  found  in 
the  pores  of  the  skin.  In  the  new- 
born they  are  white. 

Conception  (kon-sep'shun).  The 
impregnation  of  the  ovum  by  the 
spermatozoid.  The  beginning  of 
pregnancy,  p.  40. 

Condy’s  fluid  ( kon'dez).  An  anti- 
septic preparation  of  permanganate 
of  potash. 

Congenital  (kon-jen'it-al).  Exist- 
ing at  or  before  birth. 

Congestion  1 kon-jest'yun).  Exces- 
| sive  accumulation  of  blood  in  a part. 

Conjugata  vera  (kon-ju-ga'ta 
| ve'ra)  [L.].  The  internal  pelvic  diam- 


468 


GLOSSARY 


eter  measured  from  the  promontory 
of  the  sacrum  to  the  upper  margin  of 
the  pubic  joint. 

Conjunctiva!  kon-junk-ti'vahjfL.]. 
The  mucous  membrane  which  lines 
the  eyelids  and  covers  the  eyeball. 

Conjunctival  (kon  - junk  ' tiv  - al). 
Relating  to  the  conjunctiva. 

Conjunctivitis  (kon-junk-tiv-i'tis). 
Inflammation  of  the  conjunctiva. 

Contraindiction  (kon"tra  - in  - di  - 
ka'shun).  A condition  that  renders 
some  particular  line  of  treatment  im- 
proper or  undesirable. 

Convalescence  (kon  - val  - es ' ens). 
The  stage  of  recovery. 

Convalescent  kon-val-es'ent).  Re- 
gaining health  after  illness.  C.  diet, 
any  simple,  easily  digested  food  suit- 
able for  a convalescent  patient. 

Convulsion  (kon  - vul ' shun).  A 
spasm  ; a series  of  violent  involun- 
tary contractions  of  a muscle  or  set 
of  muscles. 

Coprostasis  (kop-ros'tas-is).  Cos- 
tiveness ; constipation ; undue  reten- 
tion of  feces  in  the  bowels. 

Cornea  (kor'ne-ah).  The  trans- 
parent, convex,  and  nearly  circular 
anterior  portion  of  the  eyeball. 

Coronal  (kor'o-nal).  Relating  to 
the  crown  of  the  head.  C.  or  coro- 
nary suture,  the  suture  formed  by 
the  junction  of  the  frontal  with  the 
parietal  bones. 

Coryza  (ko-ri'zah).  Cold  in  the 
head ; an  acute  catarrh  of  the  nasal 
mucous  membrane. 

Couveuse  (koo-vez')  [Fr.].  An  in- 
cubator. p.  368. 

Cranioclasis  (kra  - ne  - ok ' las  - is). 
The  crushing  of  the  fetal  skull.  See 
Craniotomy,  p.  198. 

Cranioclast  ( kra'ne-o-klast).  An 
instrument  for  crushing  the  fetal 
skull,  p.  198. 

Craniotomy(kra-ne-ot'o-me).  The 
operation  of  cutting  or  breaking  down 
the  fetal  head.  C.  scissors,  an  S- 
shaped  scissors  for  performing  crani- 
otomy. p.  199. 

Crede’s  method  for  preventing 
ophthalmia  (kreh-days').  The  appli- 
cation of  a drop  2 per  cent,  silver 
nitrate  solution  to  the  eye  of  the  new- 
born, followed  by  normal  salt  solution. 
C.’s  method  of  expelling  placenta, 


a method  of  expelling  the  placenta. 
The  operator  grasps  the  fundus  of  the 
uterus  (through  the  abdominal  wall) 
and  with  moderate  pressure  squeezes 
out  the  placenta,  “ as  the  seed  of  a 
ripe  cherry  compressed  between  the 
fingers.” 

Crenasol  (kren'as-ol).  A disinfec- 
tant. 

Crotchet  (krot'chet).  A curved, 
hook-like  instrument  for  extracting 
the  fetus  after  craniotomy ; it  is  no 
longer  used. 

Curd  (kurd).  The  coagulum  of 
milk.  It  is  mostly  casein. 

Curet  (ku-ret')  [Fr.].  A kind  of 
scraper  or  spoon  for  removing  growths 
or  other  materials  from  the  walls  of 
cavities. 

Curetment  (ku-ret'ment).  Same 
as  Curettage,  p.  224. 

Curettage  (ku-ret-tazh').  Treat- 
ment by  the  curet.  p.  224. 

Cutaneous  (ku-ta'ne-us).  Pertain- 
ing to  the  skin. 

Cutis  (ku'tis).  1.  The  skin.  2. 
The  true  skin,  or  cutis  vera. 

Cyanosis  (si-an-o'sis),  Blueness  of 
the  skin  caused  by  deficient  amount 
of  oxygen  in  the  blood,  p.  337. 

Cyanotic  (si  - an  - ot ' ikj.  Affected 
with  cyanosis. 

Cystitis  (sis-ti'tis).  Inflammation 
of  the  bladder,  p.  303. 

Cystoscope  (sis'to-skop).  An  in- 
strument for  examining  the  interior 
of  the  bladder.  To  cystoscope  : to 
look  into  the  bladder. 


D. 

Debility  (de-bil'it-e).  Weakness ; 
loss  of  power. 

Decapitation  (de  - kap  - it-a'  shun). 
The  removal  of  the  head  of  the  fetus 
in  embryotomy,  p.  197. 

Decidua  (de-sid'u-ah).  The  mem- 
branous structure  produced  during 
pregnancy  and  thrown  off  after  par- 
turition. It  is  composed  of  the  greatly 
changed  mucous  membrane  of  the 
uterus.  D.  reflex'a,  that  portion  of 
the  decidua  which  is  reflected  over 
the  ovum,  surrounding  it.  D.  serot'- 
ina,  that  part  of  the  decidua  which 
lies  under  the  maternal  portion  of  the 


GLOSSARY 


469 


placenta.  D.  ve'ra,  that  portion  of 
the  decidua  which  lines  the  uterus. 

Decomposition  (de"kom-po-zish'- 
un).  1.  The  separation  of  compound  | 
substances  into  their  constituent  parts. 
2.  Putrefaction  or  decay. 

Decubitus  tde-ku'bit-us).  1.  The 
act  of  lying  down.  2.  A bed-sore, 
p.  242. 

Defecation (def-ek-a'shun).  Evacu- 
ation of  the  bowels. 

Delirium  (de-lir'e-um).  Derange- 
ment of  the  mind,  characterized  by 
wandering  speech,  wakefulness,  and 
excitement. 

Delivery  (de-liv'er-e).  1.  The  ex- 
pulsion or  extraction  of  the  child  at 
birth.  2.  Removal  of  a part  from 
the  body — e.  g.,  the  placenta. 

Denudation  (den-u-da'shun).  1. 
The  act  of  laying  bare.  2.  The  re- 
moval of  the  epithelium. 

Denuded  (de-nu'ded).  Laid  bare. 

Desquamation  (des-kwa-ma'shun). 
The  peeling  off  of  skin  in  flakes. 

Detritus  (de-tri'tus).  Broken-down 
material,  waste. 

Diagnosis  di-ag-no'sis).  The  art 
or  science  of  distinguishing  one  dis- 
ease from  another  by  means  of  signs 
and  symptoms. 

Diagnostic  (di-ag-nos'tik).  Dis- 
tinctive ; indicating  the  nature  of  a 
disease  ; furnishing  a diagnosis. 

Diaphoresis  (di"af-o-re'sis).  Per- 
spiration, especially  profuse  perspira- 
tion. 

Diaphoretic  (di'af-o-re'tik).  1. 
Causing  diaphoresis.  2.  A drug  that 
causes  sweating. 

Diaphragm  di'af-ram).  The  mus- 
culomembranous  partition  between 
the  chest  and  abdomen,  and  the  most 
important  muscle  of  respiration. 

Diathesis  (di-ath'es-is).  Natural 
predisposition  to  a certain  disease. 

Diet  (di'et).  1.  Victuals;  habitual 
food.  2.  Course  of  food  selected  with 
reference  to  a particular  state  of 
health.  D.  sheet,  a written  or  printed 
diet-list. 

Dietary  (di'et-a-re).  A regular  or  [ 
systematic  scheme  of  diet. 

Dietetic  ''di-et-et'ik).  Pertaining 
to  diet.  D.  treatment,  treatment  of 
disease  by  means  of  a regulation  of 
diet. 


Differential  (dif-fer-en'shal).  Dis- 
criminating; showing  a difference. 
D.  diagnosis,  discriminating  between 
two  diseases  which  present  a similar 
group  of  symptoms. 

Dilute  (di-lewt'j.  1.  To  make  thin. 
2.  To  diminish  the  strength,  flavor, 
or  color  of.  3.  To  become  thin  or 
attenuated. 

Disintegration  (dis  - in  - te-gra'- 
shun).  Decay.  The  separation  of  a 
substance  into  its  component  parts. 

Diuresis  (di-u-re'sis).  Increased 
secretion  of  urine. 

Diuretic  (di-u-ret'ik).  1.  Produc- 
ing diuresis.  2.  A drug  that  causes 
increased  flow  of  urine. 

Douche  (doosh).  A stream  of 
water  directed  against  a part  or  into 
a cavity,  p.222. 

Dropsy  (drop'se).  The  abnormal 
accumulation  of  serous  fluid  in  the 
tissues  or  cavities  of  the  body. 

Duct  (dukt).  A passage  with  well- 
defined  walls ; especially,  a tube  for 
the  passage  of  a secretion  or  fluid. 

Ductus  (duk'tus).  A duct.  D.  ar- 
terio'sus,  a blood-vessel  in  the  fetus 
communicating  directly  between  the 
pulmonary  artery  and  the  aorta.  D. 
veno'sus,  a bipod-vessel  in  the  fetus 
communicating  directly  between  the 
umbilical  vein  and  the  descending 
vena  cava. 

Dysmenorrhea  (dis"men-or-re'- 
ah).  Painful  or  difficult  menstrua- 
tion. 

Dyspnea  (disp-ne'ah).  Difficult  or 
labored  breathing. 

Dystocia,  Dystokia  (dis-to'se-ah, 
dis-to'ke-ah).  Painful,  slow,  or  dif- 
ficult labor.  Fetal  d.,  dystocia  due 
to  malposdion  or  malformation  of  the 
fetus.  Maternal  d.,  dystocia  due  to 
some  deformitv  on  the  part  of  the 
mother.  Placental  d.,  difficulty  in 
removing  the  placenta. 

E. 

Ecchymosis  (ek-ke-mo'sis).  An 
extravasation  of  blood  under  the 
skin  or  mucous  membrane. 

Eclampsia  (ek-klamp'se-ah).  A 
sudden  attack  of  convulsions  occur- 
ring during  pregnancy,  labor,  or  just 
after  labor,  p.  256. 


4;o 


GLOSSARY 


Ectopic  (ek-top'ik).  Out  of  the 
normal  place.  E.  gestation,  preg- 
nancy in  which  the  fetus  is  not  in  the 
uterus.  See  Extra-uterine  pregnancy. 
E.  pregnancy,  same  as  Ectopic  ges- 
tation. E.  sac,  the  amniotic  sac  and 
its  coverings  in  ectopic  gestation, 
p.  252. 

Eczema  (ek'ze-mah).  A non-con- 
tagious skin  disease  whose  prominent 
manifestations  are  the  formation  of 
small  vesicles  closely  crowded  to- 
gether, and  an  intolerable  itching  and 
burning  of  the  affected  part.  E.  in- 
tertri'go,  an  eczematous  condition 
in  the  folds  of  fat  babies ; chafe,  p. 
343- 

Eczematous  (ek-zem'at-ous).  Af- 
fected with  eczema. 

Eliminate  (e-lim'in-at).  To  ex- 
pel ; to  throw  off  waste  matter. 

Elimination  (e-lim-in-a'shun). 
The  act  of  throwing  off  waste 
matter. 

Emaciation  (e-ma-she-a'shun).  A 
wasted  condition  of  the  body.  Loss 
of  flesh. 

Embolism  (em  'bol-izm).  The 
plugging  of  a blood-vessel  by  a clot 
or  other  obstruction  which  has  been 
carried  to  this  place  by  the  blood 
current.  Air  e.,  passage  of  air  in 
injurious  quantities  to  the  heart  and 
circulation,  p.  128. 

Embolus  (em'bo-lus).  A clot  or 
other  obstruction  of  a blood-vessel 
which  has  been  carried  from  a distant 
vessel  and  lodged  in  a smaller  one, 
obstructing  the  circulation. 

Embryo  (em'bre-o).  The  fetus 
before  the  end  of  the  third  month  of 
development. 

Embryotomy  (em-bre-ot'o-me). 
The  destruction  of  the  fetus  in  the 
uterus,  p.  198. 

Emetic  (e-met'ik).  1.  Causing 
vomiting.  2.  A drug  which  causes 
vomiting. 

Emmenagogue  (em-men'ag-og). 
1.  A drug  having  the  power  to  stim- 
ulate the  menstrual  flow.  2.  Aiding 
the  function  of  menstruation. 

Emprosthotonos  (em-pros-thot'o- 
nos).  Spasm  causing  the  body  to 
bend  forward. 

Emulsion  (e-mul'shun).  A milk- 
like mixture  prepared  by  uniting  oil 


and  water  by  means  of  another  sub- 
stance, usually  a mucilage. 

Emunctory  le-munk'to-re).  1.  Ex- 
cretory. 2.  An  excretory  duct. 

Enema  (en'e-mah).  A medicine 
or  fluid  injected  into  the  rectum, 
either  to  procure  an  evacuation  or 
for  nourishment. 

Enervation  (en-er-va'shun).  Lan- 
guor; weakness;  lack  of  nervous 
energy. 

Engagement  (en-gaj'-ment).  The 
entrance  of  the  fetal  head  into  the 
superior  strait  of  the  pelvis. 

Ensiform  (en'si-form).  Sword- 
shaped. E.  appen'dix,  E.  car'tilage, 
E.  pro'cess,  the  lower  extremity  of 
the  breast-bone. 

Enteritis  ien-ter-i'tis).  Inflamm  1- 
tion  of  the  small  intestine. 

Epidemic  (ep-id-em'ik).  1.  A dis- 
ease which  is  widely  prevalent.  2. 
The  season  of  prevalence  of  an  epi- 
demic disease. 

Epilepsy  (ep'il-ep-se).  The  falling 
sickness ; a chronic  nervous  disease 
characterized  by  convulsions  or  fits, 
and  in  which  there  is  loss  of  con- 
sciousness. 

Epileptic  (ep-e-lep'tik).  1.  Per- 
taining to  epilepsy.  2.  A person  af- 
fected with  epilepsy. 

Epileptiform  (ep-e-lep'te-form). 
Resembling  epilepsy.  See  Eclampsia. 

Episiotomy  (ep-iVe-ot'o-me).  An 
incision  of  the  vulvar  orifice,  to  per- 
mit the  fetus  to  pass.  p.  61. 

Epithelium  (ep-ith-e'le-um).  Cuti- 
cle, the  covering  of  the  true  skin 
and  mucous  membrane. 

Ergot  ( er'got).  A drug  having  the 
power  to  stimulate  uterine  contrac- 
tion. It  is  used  to  check  hemorrhage 
after  labor,  and  to  arrest  hemorrhages 
from  any  organ;  to  relieve  congestion 
of  the  brain  and  spinal  cord.  Dose, 
15-60  minims  (1-4  c.c.). 

Ergotin  (er'go-tin).  The  active 
principle  of  ergot.  Dose,  \ grain 
(0.0042-0.033  gm.). 

Erosion  (e-ro'zhun).  An  eating  or 
gnawing  away ; a kind  of  ulcera- 
tion. 

Erysipelas  (er-is-ip'el-as).  An 
acute  contagious  disease  caused  by  a 
germ,  Streptococ'cus  ery sip  el' at  is,  and 
characterized  by  chill,  high  fever,  and 


GLOSSARY 


47 


intense  local  redness  and  swelling  of 
the  skin  and  mucous  membrane. 

Eustachian  tube  (u-sta'ke-an  tub). 
The  canal  extending  from  the  phar- 
ynx to  the  middle  ear,  or  tympanum. 
E.  valve,  a semilunar  valve  in  the 
heart  at  :he  opening  of  the  inferior 
vena  cava. 

Eutocia,  Eutokia  (u-to'she-ah, 
u-to'ke-ah).  Normal  labor. 

Evacuation  (e-vak-u-a'shun).  i. 
The  act  of  moving  the  bowels.  2.  The 
discharge  from  the  bowels. 

Evisceration  (e  - vis  - er  -a'shun). 
Removal  of  the  bowels  or  viscera  from 
the  body.  Obstetric  e.,  removal  of 
viscera  of  the  fetus  in  embryotomy. 

Exacerbation  (ex-as-er-ba'shun). 
1.  Increase  in  severity  of  the  symp- 
toms of  a disease.  2.  The  stage  of 
periodic  increase  in  the  severity  of 
symptoms. 

Excoriation  (ex-ko-re-a'shun).  A 
superficial  loss  of  substance,  p.  342. 

Excrement  (ex'kre-ment).  Feces. 
That  which  is  excreted  by  the  bowels. 

Excrete  (ex-kret).  To  throw  off, 
as  waste  matter,  by  a normal  dis- 
charge. 

Excretion  (ex-kre'shun).  1.  The 
process  of  excreting.  2.  The  mate- 
rial which  has  been  excreted. 

Exostosis  (ex-os-to'sis).  A bony 
growth  on  the  surface  of  a bone  or 
tooth. 

Expiration  (ex-pi-ra'shun).  The 
act  of  expelling  air  from  the  lungs. 

Expiratory  1 ex-plr'a-to-re).  Per- 
taining to  expiration. 

Expire  (ex-plr').  1.  To  expel  the 
breath.  2.  To  die. 

Expulsive  (ex-pul'siv).  Driving  or 
forcing  out.  E.  pains,  those  occur- 
ring during  the  second  stage  of  labor. 
E.  stage,  the  second  stage  of  labor, 
p.  118. 

Exsanguination  (ex-sang-gwin-a'- 
shun).  The  condition  of  being  with- 
out blood,  p.  277. 

Extension  (ex-ten'shun).  A term 
applied  to  that  stage  in  the  delivery 
of  the  fetal  head  when  the  chin  is  no 
longer  flexed  on  the  chest.  The  oppo- 
site of  flexion. 

Extra-uterine  (ex-trah-u'ter-in). 
Outside  the  uterus.  E.  life,  life  after 
birth.  E.  pregnancy,  pregnancy  in 


which  the  fetus  is  not  contained  in  the 
uterus,  but  in  some  organ  outside  the 
uterus.  Ectopic  gestation,  p.  232. 

Extravasation  (ex  - trav  - as  -a 
shun).  The  escape  of  a fluid  from  its 
normal  vessel  or  cavity  into  the  sur- 
rounding tissues. 

Exudation  (ek-su-da'shun).  Ooz- 
ing ; slow  escape  of  liquid. 


F. 

Facial  (fa'shal).  Pertaining  to  the 
face.  p.  354. 

Faeces  (fe'sez).  See  Feces. 

Fallopian  (fal-lo'pe-an)  preg- 
nancy. Pregnancy  occurring  in  the 
Fallopian  tubes  ; same  as  tubal  preg- 
nancy. F.  tubes,  the  oviducts:  two 
canals  leading  from  the  ovaries  to  the 
body  of  the  uterus.  Fig.  15. 

Farinaceous  (far-in-a'shus).  Con- 
taining flour  : said  of  certain  diets. 

Fauces  (faw'ses).  The  back  part 
of  the  mouth  leading  into  the 
pharynx. 

Febrile  (feb'ril).  Pertaining  to 
fever.  Feverish. 

Fecal  (fe'kal).  Pertaining  to  feces  ; 
containing  feces. 

Feces  (fe'sez).  The  excrement  or 
undigested  residue  of  the  food  dis- 
charged from  the  bowels. 

Fecundation  (fe-kun-da'shun). 
The  fertilization  of  the  ovum  by  means 
of  the  spermatozoid.  p.  40. 

Fenestrated  ( fen'es-tra-ted).  Hav- 
ing openings,  or  fenestra. 

Fetus  (fe'tus)  [L.].  The  child  in 
iitero  from  the  end  of  the  third  month 
of  development  till  birth. 

Fillet  (fil'let).  A loop  of  tape  used 
for  making  traction. 

Finger  cot  (fing'ger  kot).  A thin 
rubber  covering  for  the  finger.  Occa- 
sionally used  as  a dressing  for  a 
wound  of  the  finger. 

Fissure  (fish'ur).  A crack  or  nar- 
row opening,  p.  313. 

Flex  (flex).  To  bend,  as  a joint. 

Flexion  (flex'shun).  1.  The  act  of 
bending.  2.  The  state  or  condition 
of  being  bent.  F.  stage,  that  stage 
in  labor  in  which  the  chin  of  the  fetus 
is  pressed  against  its  breast. 

Flocculus  (flok'u-lus),  pi ..floc'culi 


472 


GLOSSARY 


[L.].  A small  shred  or  flake,  usually 
floating  in  a liquid. 

Fontanel,  Fontanelle  (fon-tan-el'). 
The  quadrangular  space  at  the  junc- 
tion of  the  frontal  with  the  two  pari- 
etal bones  in  infants.  “ The  soft 
spot.”  The  other  junctions  of  the 
cranial  bones  are  also  called  fonta- 
nels. p.  43. 

Foramen  (for-a'men),  pi.,  foram'- 
ina  [L.].  A hole  or  opening,  especi- 
ally through  bone.  F.  ova'le,  an 
opening  in  the  partition  between  the 
auricles  in  the  fetus. 

Forceps  (for'seps).  A two-bladed 
instrument  for  grasping  and  holding 
that  to  which  it  is  applied.  Obstetric 
f.,  the  instrument  used  to  extract  the 
child's  head.  p.  190. 

Formaldehyd  (for-mal'de-hid).  1. 
A powerful  disinfectant  gas.  2.  An 
aqueous  solution  of  the  gas  is  used  as 
a surgical  antiseptic  and  preservative 
for  specimens,  p.  443. 

Formula  (for'mu-lah).  1.  A pre- 
scribed method  for  preparing  a medi- 
cine. 2.  A combin  ition  of  symbols 
used  to  express  the  chemical  consti- 
tution of  a substance. 

Fornix  (for'nix).  Arch  or  vault. 
F.  of  the  vagina,  the  hollow  plrces 
between  the  cervix  and  the  anterior, 
posterior,  and  lateral  walls  of  the 
vagina. 

Fourchet  (foor-shet')  [Fr.].  The 
fold  of  mucous  membrane  at  the  pos- 
terior junction  of  the  labia  majora. 

Friable  (fri'ab-l).  Easily  pulver- 
ized. 

Function  (funk'shun).  The  special 
office  of  an  organ. 

Fundus  (fun'dus)  [L.].  The  base 
or  part  of  a hollow  organ  remotest 
from  its  mouth.  F.  u'teri,  the  part 
of  the  uterus  which  is  most  remote 
from  the  cervix  or  os. 

Funis  (tu'nis).  The  umbilical  cord. 

Furunculus  (fu-rung'ku-lus).  A 
boil. 

G. 

Galactagogue  (gal-ak'tag-og).  1. 
Increasing  the  secretion  of  milk.  2. 
A drug  having  the  power  to  increase 
the  flow  of  milk.  p.  322. 

Galactorrhea  ( gal-ak-tor-rhe'ah). 
Excessive  secretion  of  milk.  p.  321. 


Galactostasis.  Cessation  or  stag- 
nation of  the  milk-secretion. 

Gastric  (gas'trik).  Pertaining  to 
the  stomach. 

Gavage  (gah-vazh')  [Fr.].  1. 

Feeding  by  the  stomach-tube.  2.  The 
employment  of  a very  full  diet.  p.  381. 

Genital  (jen'it-al).  Pertaining  to 
generation,  or  to  the  organs  of  gen- 
eration. p.  31. 

Genupectoral  (je-nu-pek'tor-al). 
Relating  to  the  knees  and  chest.  G. 
position,  “knee -chest  position.'1 
That  posture  in  which  the  patient 
rests  on  the  knees  and  chest,  the 
thighs  extending  upward,  the  but- 
tocks being  as  high  as  possible,  p. 
238. 

Germicidal  ( jer-mis-i'dal).  De- 
structive to  germs. 

Germicide  ( jer'mis-Id).  An  agent 
having  the  power  to  destroy  germs. 

Gestation  ( jes  - ta  ' shun).  Preg- 
nancy. p.  49. 

Gland  (gland).  An  organ  which 
separates  a fluid  from  the  blood. 

Glandular  (gland'u-lar).  1.  Hav- 
ing the  nature  of  a gland.  2.  Fur- 
nished with  glands. 

Gians  (glanz),  pi glan' des.  Latin 
for  Gland.  The  distal  end  or  head 
of  the  penis  or  clitoris,  p.  339. 

Graafian  follicle  (grah'fe-an  fol'- 
lik-1).  Small  spherical  bodies  in  the 
ovary,  each  containing  an  ovum. 

Granulation  (gran-u-la'shun).  The 
formation  in  wounds  of  small, 
rounded,  fleshy  masses ; also  a mass 
so  formed. 

Gravid  uterus  (grav'id  u'ter-us). 
Pregnant  uterus. 

Gravida  (grav'id-ah)  [L.].  A preg- 
nant woman. 

Gravidity  (grav  - id ' it  - e) . Preg- 

nanev. 

Gum,  red  (gum).  Strophulus,  a 
reddish  eruption  on  the  skin  of  the 
new-born.  White  g.,  strophulus  al- 
bus ; a whitish  eruption  on  the  skin 
of  the  new-born.  p.  342. 

Gynecic  (jin-e'sik).  Relating  to 
women. 

Gynecologist  ( jin  - e - kol ' o-jist). 
One  who  is  skilled  in  gynecology. 

Gynecology  ( jin-e-kol'o-je).  That 
branch  of  medicine  which  treats  of 
I women’s  constitution  and  diseases. 


GLOSSARY  473 


H. 

Harelip  (har'lip).  A congenital 
slit  in  the  upper  lip,  sometimes  double. 
P-  356. 

Hebosteotomy.  Section  of  the  bone 
at  the  side  of  tne  pubic  symphysis, — 
pubiotomy. 

Hematoma  An  accumulation  of 
blood  in  the  tissues. 

Hematemesis  (hem-at-em'es-is). 
The  vomiting  of  blood. 

Hematosalpinx  (hem"at  - o - sal'- 
pinx).  Distention  of  the  Fallopian 
tube  with  blood. 

Hemorrhage  (hem'or-rej).  The 
escape  of  blood  from  its  natural  chan- 
nels. p.  272. 

Hemorrhoid  (hem'or-roid).  A pile; 
a vascular  tumor  of  the  mucous  mem- 
brane of  the  rectum.  External  h., 
appearing  external  to  the  anus.  In- 
ternal h.,  within  the  anus.  p.  34. 

Hernia  (her'ne-ah)  [L.].  The  pro- 
trusion of  an  organ,  or  part  of  an  or- 
gan, through  an  abnormal  opening; 
rupture,  p.  358. 

Heterogeneous  (het"er-o-je/ne- 
us).  Of  dissimilar  nature. 

High  forceps  (hi  for'seps).  The 
application  of  the  forceps  to  the  fetal 
head  as  it  enters  the  brim  of  the  pel- 
vis. p.  193. 

Hirsute  (her'sut).  Covered  with 
hair. 

Homogeneous  ( ho  - mo  - je'ne-us). 
Of  a similar  nature. 

Hydragogue  (hi'dra-gog).  A drug 
having  the  power  to  increase  the 
glandular  secretions,  and  producing 
profuse  watery  discharges  from  the 
bowels. 

Hydrometer  (hi-drom'et-er).  An 
instrument  for  measuring  the  specific 
gravitv  of  fluids. 

Hygiene  (hi-jen').  The  science  of 
health  and  its  preservation. 

Hygienic  (hi-je-en'ik).  Pertaining 
to  hygiene  or  to  health. 

Hygrometer  (hi-grom'et-er).  An 
instrument  for  measuring  the  mois- 
ture of  the  atmosphere,  p.  372. 

Hymen  (hi'men).  The  membranous 
fold  which  partly  closes  the  entrance 
to  the  vagina,  especially  in  the  virgin. 

Hyperemesis  (hi- per-em'e-sis). 
Excessive  vomiting,  p.  238. 


Hypersecretion  (hi"per-se-kre/- 

shun  . Excessive  secretion. 

Hypertrophy  (hi-per'tro-fe).  The 
unnatural  overgrowth  of  an  organ  or 
part. 

Hypodermatic,  Hypodermic  (hi"- 
po  - der  - mat ' lk,  hi-po-der'iriik ).  1. 

Pertaining  to  the  application  of  medi- 
cine under  the  skin.  2.  A medicine 
introduced  under  the  skin.  H.  in- 
jection, the  injection  of  medicine  or 
nutrient  solutions  under  the  skin.  H. 
needle,  the  hollow  needle  of  a hypo- 
dermic syringe.  H.  syringe,  a small 
syringe  for  injecting  fluid  under  the 
skin. 

Hypodermoclysis  (hi " po  - der  - 

mok'lis-is).  Introduction  into  the 
subcutaneous  tissue  of  fluids  in  large 
quantity,  p.  225. 

Hypogastric  arteries  (hi-po-gas'- 
trik).  The  umbilical  arteries.  They 
form  part  of  the  umbilical  cord. 

Hysteria  (his  - te're  - ah).  A ner- 
vous disease,  mainly  of  young 
women,  characterized  by  lack  of 
control  over  acts  and  emotions. 

Hysterotomy  (his-ter-ot'o-me). 
Cesarean  section,  p.  201. 

I. 

Icterus  neonatorum  (ik'ter-us  ne- 
o-na'tor-um).  The  jaundice  some- 
times seen  in  the  new-born.  pp.  69, 
34i- 

Iliac  (il'e-ak).  Pertaining  to  the 
ilium  or  flank.  I.  artery,  one  of 
the  two  branches  of  the  abdominal 
aorta.  I.  fossa,  the  broad,  shallow 
cavity  at  the  upper  part  of  the  inner 
surface  of  the  ilium. 

Ilium  (il'e-um),  pi.,  il'ia  |~L.].  The 
broad,  flat,  upper  part  of  the  innomi- 
nate bone. 

Impregnation  (im-preg-na'shun). 
The  act  of  making  pregnant ; fecun- 
dation. p.  40. 

Impression,  maternal  (im-presh'- 
un,  mat-er'nal).  The  effect  produced 
on  the  fetus  in  utero  by  the  mental 
and  other  experiences  of  the  mother 
during  pregnancy,  p.  82. 

Inanition  fever  (in-an-ish'un  fe'- 
ver).  A fever  in  infants,  due  to  wast- 
ing of  the  body  from  lack  of  nourish- 
ment. p.  333/ 


474 


GLOSSARY 


Incise  (in-siz').  To  cut  in  or  into, 
as  with  a knife. 

Incised  wound  (in-sizd'  woond). 
A wound  made  with  a sharp  knife. 

Incision  i in-sizh'un).  A wound 
made  by  cutting ; a cut. 

Incontinentia  paradoxa  (in-kon- 
tin-en'she-ah  par-ad-oks'ah).  Filling 
of  the  bladder  with  urine,  overflow 
and  dribbling  away  of  urine,  pp.  67, 
248. 

Incubator  (in'ku-ba-tor).  An  ap- 
paratus for  rearing  prematurely  born 
children  ; a couveuse.  p.  368. 

Indurated  (in'du-ra-ted).  Hard- 
ened ; rendered  hard. 

Induration  (in-du-ra'shun).  An 
abnormally  hard  spot  or  place. 

Infection  (in-fek'shun).  1.  The 
communication  of  disease  from  one 
person  to  another.  2.  The  agent  by 
which  a disease  is  conveyed.  Septic 
i.,  infection  caused  by  pus-producing 
germs,  p.  279. 

Infectious  (in-fek'shus).  Liable  to 
be  communicated  by  infection. 

Inflammation  (in-flam-ma'shun  1. 
A diseased  condition  characterized 
by  heat,  pain,  redness,  and  swelling, 
with  or  without  fever. 

Infusion  (in  - fu  ' zhun).  1.  The  I 
steeping  of  a substance  in  water  to  ' 
obtain  its  medicinal  properties.  2. 
The  injection  of  a hot  normal  salt 
solution,  0.6  per  cent.,  into  a blood- 
vessel or  subcutaneous  tissue.  Arte- 
rial i.,  infusion  into  an  artery  Sub- 
cutaneous i.,  injection  of  the  salt 
solution  into  the  loose  subcutaneous 
tissue.  The  usual  locations  are  under 
the  breast  and  over  the  shoulder- 
blades.  Venous  i.,  infusion  into  a 
vein.  Fig.  118. 

Ingesta  (in-jes'tah).  Food  taken 
into  the  stomach. 

Ingestion  (in-jest'shun).  The  act 
of  taking  food  into  the  stomach. 

Inhalation  (in-hal-a'shun).  1.  The 
drawing  of  air  or  other  vapor  into  the  I 
lungs.  2.  A substance  to  be  inhaled  I 
as  a vapor. 

Inlet  (in'let).  The  upper  limit  of  ' 
the  cavity  of  the  pelvis.  Fig.  5. 

Innominate  (in-nom'in-at).  Not  ! 
having  a name  ; nameless.  I.  bone, 
the  hip-bone  ; it  consists  of  the  ilium, 
the  ischium,  and  the  os  pubis. 


Innominatum  (in-nom-in-a'tum). 
The  innominate  bone.  Fig.  4. 

Insomnia  (in-som'ne-ah  1.  Inabil- 
ity to  sleep ; abnormal  wakefulness, 
p.  306. 

Inspiration  (in-spi-ra'shun ).  The 
act  of  drawing  air  into  the  lungs. 

Inspiratory  (in'spir-a-to-re).  Per- 
taining to  inspiration.  I.  muscles, 
those  muscles  which,  by  their  con- 
traction, assist  in  inspiration. 

Intertrigo  (in-ter-tri'go).  A chaf- 
ing of  the  skin  in  moist  situations,  as 
about  the  anus  and  vulva,  and  in  the 
arm-pits;  chafe,  p.  343. 

Intestine  (in-tes'tin).  The  bowel. 
The  long  membranous  tube  that  ex- 
tends from  the  stomach  to  the  anus. 

Introitus.  (in-tro-i-tus).  The  en- 
trance to  the  vagina. 

Inunction  (in-unk'shun).  The  a<  t 
of  applying  an  ointment  with  friction. 

In  utero  (in  u'ter-o).  Inside  the 
uterus. 

Inversion  (in-ver'shun).  Turning 
inside  out  or  upside  down.  I.  of 
the  uterus,  the  turning  inside  out  of 
the  uterus.  It  may  be  due  to  pulling 
on  the  cord,  a heavy  placenta,  or  to 
the  violent  efforts  of  the  patient. 

Involution  (in-vo-lu'shun).  The 
return  of  the  uterus  to  its  normal  size 
after  labor,  p.  64. 

Irrigation  (ir-ig-a'shun).  1.  Wash- 
ing by  a stream  of  water  or  other  lo- 
tion. 2.  The  liquid  used  for  irrigation. 

Ischium)  is'ke-um),  pi.,  is'chia[ L.]. 
The  lower,  posterior  part  of  the  in- 
nominate bone.  It  is  separate  from 
it  in  fetal  life  and  infancy. 

Ischuria  (is-ku're-ah  ).  Difficult 
urination.  I.  paradox'a,  overflow 
of  the  full  bladder.  See  Incontinentia 
paradoxa.  pp.  67,  248. 

J. 

Jactitation  (jak-tit-a'shun).  The 
tossing  and  restlessness  of  a patient 
in  acute  disease. 

Jaundice  (jawn'dis)  [L.,  ic'terus\. 
Yellowness  of  the  skin,  eyes,  and  se- 
cretions, due  to  the  presence  of  bile- 
pigments  in  the  blood.  Icterus,  pp. 
69,  341. 

Jelly  of  Wharton  (jel'e).  The 
soft  pulpy  tissue  of  the  umbilical  cord. 


GLOSSARY 


475 


K. 

Kleptomania  (klep-to-ma'ne-ah). 
A nervous  affection  characterized  by 
a desire  to  steal. 

Knee-chest  position  (ne-chest  po- 
zish'un).  That  position  in  which  the 
patient  rests  flat  on  the  chest  and 
knees,  with  the  hips  elevated  as  high 
as  possible,  and  the  thighs  extending 
vertically ; same  as  genu-pectoral,  p. 
238. 

Kumiss  (koo ' mis).  A nutritive 
food  prepared  originally  from  mare’s 
milk,  now  from  cow’s  milk. 

Kyphosis  (ki-fo'sis).  Hump- 
backed curvature  of  the  spine. 


L. 

Labia  (la'be-ah)  [L.].  The  plural 
of  la'bium.  Lips,  or  parts  resembling 
lips.  L.  majo'ra,  the  folds  of  skin  and 
fat  which  form  each  side  of  the  vulva. 
L.  mino'ra,  the  folds  of  mucous 
membrane  inside  the  labia  majora ; 
the  nymphae. 

Labor  (la'bor).  Parturition.  The 
expulsion  of  the  fetus  from  the  uterus. 
Dry  1.,  labor  in  which  there  is  a lack 
of  amniotic  fluid.  Induced  1.,  labor 
artificially  brought  on.  Missed  1., 
retention  of  the  dead  fetus  in  the 
uterus  beyond  the  normal  period  of 
pregnancy.  Precipitate  1.,  labor  of 
abnormally  short  duration.  Prema- 
ture 1.,  labor  occurring  before  the 
normal  time.  Spontaneous  1.,  labor 
without  artificial  aid. 

Laceration  (las-er-a'shun).  1.  The 
act  of  tearing.  2.  A wound  made  by 
tearing;  in  obstetrics,  referring  to 
the  perineum,  pp.  131,  139. 

Lactation  (lak-ta'shun).  1.  The 
secretion  of  milk.  2.  The  period  of 
milk-secretion.  3.  The  suckling  of 
the  infant,  p.  65. 

Lacteal  (lak'te-al).  1.  Pertaining 
to  milk.  2.  One  of  the  intestinal 
lymphatics  that  take  up  chyle.  L. 
calculus,  a concretion  of  thickened 
milk  in  one  of  the  milk-ducts.  L. 
swelling,  a swelling  of  the  breast 
from  an  accumulation  of  milk. 

Lactiferous  (lak-tif'er-us).  Pro- 
ducing or  conveying  milk.  pp.  35,65. 


Lactometer  (lak-tom'e-ter).  An 
instrument  for  finding  the  specific 
gravity  of  milk. 

Lambdoid,  Lambdoidal  (lam'- 
doid,  lam-doi'dal).  Shaped  like  the 
Greek  letter  A or  A.  L.  suture,  the 
suture  between  the  occipital  and  the 
two  parietal  bones,  p.  44. 

Lanugo  (lan-u'go)  [L.].  1.  The 

fine  hair  on  the  body  of  the  fetus.  2. 
The  fine  hair  found  on  nearly  all  the 
body  except  the  palms  and  soles,  p. 

365- 

Laparotomy  (lap-ar-ot'o-me).  1. 
Surgical  incision  through  the  flank ; 
celiotomy.  2.  Abdominal  section  at 
any  point. 

Larynx  (lar'inx).  The  organ  of 
voice  ; the  upper  part  of  the  trachea 
or  wind-pipe. 

Laxative  (lak'sat-iv).  Slightly 
purgative ; a medicine  which  is  mildly 
cathartic. 

Layette  (la-et')  [Fr.].  Infant’s 
wardrobe,  p.  97. 

Lesion  (le'zhun).  1.  Any  hurt, 
wound,  or  local  degeneration.  2.  A 
diseased  condition  of  a tissue. 

Lethargic  (le-thar'jik).  In  a state 
of  lethargy. 

Lethargy  (leth'ar-je).  Stupor  or 
coma.  Marked  drowsiness. 

Leukorrhea,  Leucorrhea  flu-kor- 
re'ah).  A whitish  discharge  from  the 
vagina  and  uterus;  the  whites. 

Ligature  (lig'at-ur).  A thread  or 
wire  for  tying  a blood-vessel  or  stran- 
gulating a part. 

Lightening  (lit'en-ing).  The  sink- 
ing of  the  head  into  the  pelvis  in  the 
last  weeks  of  pregnancy,  p.  55. 

Linea  (lin'e-ah).  Latin  for  Line. 
A line.  L.  al'ba  [L.  “ white  line  ”]. 
The  central  tendinous  line  extending 
from  the  sternum  to  the  pubic  bone. 
Linese  albican'tes,  “ striae  gravi- 
darum.” Shining,  whitish,  and  pur- 
plish lines  on  the  abdomen  of  preg- 
nant women  and  those  who  have 
borne  children.  They  are  some- 
times due  to  distention  from  other 
causes,  pp.  51,  52. 

Liquor  (li'kwor),  pi.,  liquo'res  [L.]. 
A fluid  or  liquid.  L.  am'nii,  the 
fluid  contained  in  the  amniotic  sac, 
and  surrounding  the  child,  p.  42. 

Lithopedion  (lith  - o - pe ' de  - on). 


476 


GLOSSARY 


“Stone-child.”  A fetus  that  has  died 
and  become  changed  into  a hard 
mass  of  calcareous  matter. 

Lithotomy  (lith-ot'o-me).  The  re- 
moval of  a stone  by  cutting  into  the 
bladder;  cystotomy.  L.  position, 
the  patient  lies  on  the  back,  with  the 
legs  and  thighs  well  flexed,  the  knees 
widely  separated,  and  hips  well  over 
the  edge  of  the  table,  pp.  185,  186. 

Lochia  (lo'ke-ah).  The  vaginal 
and  uterine  discharge  occurring  for 
several  days  after  delivery.  L.  al/ba, 
the  whitish  discharge  normal  after  the 
first  ten  days  of  the  puerperal  state. 
L.  cruen'ta,  L.  ru'bra,  the  blood- 
stained discharge  occurring  the  first 
week  after  delivery.  L.  sanguin- 

olen'ta,  the  watery  bloody  discharge 
from  the  third  to  sixth  day.  L.  sero- 
sa, the  pinkish  or  serous  discharge 
after  the  first  ten  days.  pp.  63,  64. 

Lochial  (lo'ke-al).  Pertaining  to 
the  lochia. 

Low  forceps  (15  for'seps).  For- 
ceps applied  to  the  fetal  head  at  the 
outlet  of  the  pelvis,  p.  190. 

Lues.  Syphilis,  p.  449. 

Lying-in  (li-ing-in').  The  puer- 
peral state.  L.-i.  fever,  puerperal 
fever.  L.-i.  hospital,  a hospital  for 
the  care  of  women  during  pregnancy 
and  labor  and  after  confinement : a 
maternity. 

Lysis  (li'sis).  Gradual  decline  of 
fever. 

M. 

Macerated  (mas'er-a-ted).  Soft- 
ened and  broken  up  by  long-con- 
tinued action  of  a fluid  or  by  a di- 
gestive process. 

Malaise  (mal-az')  [Fr.].  Discom- 
fort or  uneasiness ; indisposition. 

Malposition  1 mal-po-zish'un).  Ab- 
normal position. 

Malpractice  (mal-prak'tis).  Im- 
proper or  injurious  practice;  unskil- 
ful or  injurious  medical  or  surgical 
treatment. 

Mamma  (mam'mah).  The  breast; 
the  mammary  gland,  p.  65. 

Mammary  (mam'ar-e).  Pertain- 
ing to  the  breast. 

Mania  (ma'ne-ah).  A form  of  in- 
sanity in  which  there  are  excitement, 


delusions,  and  tendency  to  violence. 
P-  3°4- 

Maniacal  (ma-ni'ak-al).  Affected 
with  mania. 

Manual  (man'u-al).  Pertaining  to 
the  hands  ; performed  by  the  hands. 

Marantic  (mah-ran'tik).  Having 
the  nature  of  marasmus,  p.  334. 

Marasmus  (mar-az'mus).  A dis- 
ease  of  young  children  in  which  there 
are  progressive  wasting  and  emaci- 
ation. p.  334. 

Massage  (mas-sazh').  The  sys- 
tematic employment  of  friction, 
kneading,  and  stroking  of  the  body 
as  a treatment  for  disease,  pp.  148,  309. 

Mastitis  (mas-ti'tis).  Inflamma- 
tion of  the  breast,  p.  315. 

Maternal  (mat-urn'al).  Pertaining 
to  the  mother;  derived  from  the 
mother.  M.  impression,  the  effect 
produced  on  the  fetus  in  utero  by  the 
mental  and  other  experiences  of  the 
mother  during  pregnancy,  p.  82. 

Maternity  (mat-er'nit-e).  1. 
M tnerhood.  2.  A lying-in  hospital. 
M.  nurse,  an  obstetric  nurse. 

Mauriceau  (maw-re-so').  A famous 
French  obstetrician  who  lived  in  the 
eighteenth  century. 

Meatus  (me-a'tus),  pi.,  mea'ti  [L. 
for  “ passage”].  A passage  or  open- 
ing. M.  urina'rius,  the  external 
opening  of  the  urethra,  pp.  31,  33. 

Meconium  (me-ko'ne-um)  [L.]. 
The  dark-green  substance  found  in 
the  large  intestine  of  the  fetus,  and 
evacuated  during  the  first  days.  p. 

7°. 

Median,  Mesial  (me'de-an,  me'- 
she-al).  Middle. 

Melancholia  (mel-an-ko'le-ah).  A 
form  of  insanity  with  depression  of 
spirits  and  gloomy  forebodings,  pp. 
249,  304. 

Melena  (mel-e'nah).  1.  The  pas- 
sage of  dark,  pitchy  feces,  stained 
with  blood-pigments,  or  containing 
blood.  2.  The  vomiting  of  altered 
blood  ; black  vomit,  p.  333. 

Membrane  (mem'bran).  A thin 
layer  of  tissue  covering  a surface  or 
dividing  a space.  Mucous  m.,  lining 
of  cavities  which  communicate  with 
the  external  air.  Serous  m.,  the 
lining  of  one  of  the  great  body  cavi- 
ties. 


GLOSSARY  477 


Membranes  (mem'brans).  A term 
to  indicate  theamniotic  sac.  p.  59. 

Menopause  (men  ' o - pawz). 
“ Change  of  life.”  The  period  at 
which  menstruation  ceases. 

Menses  (men'sez).  The  normal 
monthly  flow  of  blood  from  the 
uterus,  pp.  38,  73,  345. 

Menstrual  (men'stru-al).  Relat- 
ing to  the  menses. 

Menstruate  (men'stru-at).  To 
have  the  monthly  flow . 

Menstruation  (men-stru-a'shun). 
The  monthly  flow  ; the  menses  ; the 
function  of  menstruating,  p.  38. 

Mento- anterior  (men"to-an-te'- 
re-or).  Having  the  chin  directed  for- 
ward. p.  173. 

Mentoposterior  (men"to-pos-te'- 
re-or).  Having  the  chin  directed 
backward,  p.  173. 

Microscopic  (mi  - kro  - skop  ' ik). 
Visible  only  with  the  aid  of  a micro- 
scope. 

Micturition  (mik-tu-rish'un).  Uri- 
nation. 

Midwife  (mid'wif).  A woman  who 
attends  women  in  labor. 

Miscarriage  (mis-kar'rij).  A term 
used  by  the  laity  to  describe  the  ex- 
pulsion of  the  fetus  at  any  time  dur- 
ing pregnancy,  p.  55. 

Modification  (mod/,if-ik-a/shun). 
An  alteration  ; a change  of  form  or 
condition,  p.  397. 

Mole  (mol).  A fleshy  mass  formed 
in  the  uterus  by  the  degeneration  of 
an  ovum  in  the  early  months  of  preg- 
nancy. 

Mons  veneris.  The  large  pad  of 
fat  over  the  pubes,  p.  32. 

Monster  (mon'ster).  A fetus 
formed  with  an  excess,  a deficiency, 
or  a malposition  of  parts. 

Monstrosity  (mon-stros'it-e).  A 
monster. 

Montgomery’s  glands  (mont- 

gom'er-ez).  Sebaceous  glands  in  the 
areola  around  the  nipple,  p.  36. 

Monthlies  (month'lez).  The 
menses,  p.  38. 

Morbid  (mor'bid).  Diseased;  per- 
taining to  disease. 

Morbidity  (mor-bid'it-e).  1.  The 
condition  or  state  of  being  diseased. 
2.  The  sick  rate  or  proportion  of  dis- 
ease to  health  in  a community. 


Mother's  mark  (muth'erz).  Birth- 
mark ; nevus. 

Mucosa  (mu-ko'sah).  Mucous 
membrane. 

Mucous  (mu'kus).  Pertaining  to  or 
resembling  mucus.  M.  membrane, 
the  membranous  lining  of  all  cavities 
of  the  body  which  communicate  with 
the  external  air. 

Mucus  (mu'kus).  The  viscid  watery 
secretion  of  the  mucous  glands. 

Multigravida  ( m ul-te-grav 'id -ah ) . 
A woman  who  has  been  pregnant 
several  times. 

Multipara  (mul  - tip 'ar  - ah).  A 
woman  who  has  borne  several 
children. 

Mummification  (mum"mif-ik-a'- 
shun).  The  drying  and  shriveling  up 
of  the  fetus. 

N. 

Narcotic  (nar-kot'ik).  1.  Produc- 
ing sleep  or  stupor.  2.  A drug  capa- 
ble of  producing  sleep  and  relieving 
pain. 

Nates  (na'tez).  The  buttocks. 

Nausea  (naw'se-ah).  Tendency  to 
vomit.  Sickness  at  the  stomach. 

Navel  (na'vel).  The  umbilicus.  N.- 
string,  the  umbilical  cord. 

Neonatorum  (ne-o-na-to'rum).  Of 
the  new-born. 

Neonatus  (ne-o-na'tus).  The  new- 
born. p.  68. 

Nephritis  (nef-ri'tis).  Inflammation 
of  the  kidney. 

Neurotic  (nu-rot'ik).  Nervous. 
Affected  with  a nervous  disease. 

Neutral  (nu'tral).  Indifferent.  Not 
decided  nor  pronounced.  N.  reaction, 
a reaction  that  is  neither  acid  nor  al- 
kaline ; not  turning  litmus -paper 
either  red  or  blue. 

Nevus  (ne'vus).  1.  A birth-mark. 
2.  A spot  on  the  skin,  either  congen- 
ital or  acquired  after  birth. 

Nitrogenous  (ni-troj'en-us).  Con- 
tain ;ng  nitrogen. 

Nodular  (nod'u-lar).  Like  a nod- 
ule ; having  nodules. 

Nodule  (nod'ul).  A small  rounded 
mass  ; a small  node. 

Normal  (nor'mal).  Natural ; ac- 
cording to  rule. 

Nutrient  (nu'tre-ent).  1.  Nourish- 


478 


GLOSSARY 


ing.  2.  A nutritious  substance.  N. 
enema,  an  injection  into  the  rectum  j 
of  easily  digested  food  in  liquid 
form.  p.  459. 

Nutriment  (nu'trim-ent).  Nour- 
ishment. 

Nutrition  (nu-trish'un).  1.  The 
process  of  assimilating  food.  2.  Nour- 
ishment. 

Nutritious  (nu-trish'us).  Nourish- 
ing. 

Nutritive  ( nu'trit-iv).  Same  as  nu- 
trient. N.  enema,  nutrient  enema. 
P-  459- 

Nymphse  (nim'fe).  The  labia 
minora,  p.  32. 

0. 

Obstetric,  Obstetrical  (ob-stet'- 
rik,  ob-stet'rik-al).  Pertaining  to 
midwifery  or  obstetrics. 

Obstetrician  (ob-stet-rish'un).  An 
accoucheur ; one  who  is  skilled  in  the 
delivery  of  women  in  labor. 

Obstetrics  (ob-stet'riks).  The 
science  and  art  of  assisting  women 
through  pregnancy  and  labor  and 
during  the  puerperium  ; midwifery. 

Occiput  (ok'sip-ut)  [L.].  The  back 
part  of  the  head.  p.  171. 

Oleum  ricini  (o'le-um  ris'in-i). 
Castor  oil.  Dose,  3-8  drams,  p.  144. 

Oligohydramnios  (ol  " ig  - o - hi- 
dram'ne-os).  Scarcity  of  the  amniotic 
fluid. 

Opacity  (o-pas'it-e).  An  opaque 
spot ; inability  to  transmit  the  rays  of 
light. 

Ophthalmia  (of-thal'me-ah).  In- 
flammation of  the  eye  or  of  the 
mucous  membrane  lining  the  eyelids. 
0.  neonato'rum,  ophthalmia  of  the 
new-born.  p.  347. 

Organ  (or'gan).  Any  part  of  the 
body  having  a special  function. 

Os  (os).  Latin  for  month.  0.  u'teri, 
the  mouth  of  the  uterus.  0.  u'teri 
exter  num,  the  external  opening  of 
the  canal  of  the  cervix.  0.  u'teri  in- 
ter'num,  the  internal  opening  of  the 
canal  of  the  cervix,  p.  28. 

Os  (os).  Latin  for  bone.  0.  in- 
nomina'tum,  innominate  bone. 

Osmosis  (os-mo'sis).  The  passage 
of  a fluid  or  of  salts  through  a mem- 
brane. 


Outlet  (out'let).  The  lower  limit 
of  the  cavity  of  the  pelvis.  Figs.  6,  8. 

Ovarian  (o-va're-an).  Pertaining 
to  the  ovary. 

Ovary  (o'va-rc).  The  female  sexual 
gland  in  which  the  ova  are  devel- 
oped. The  ovaries  are  situated  in 
the  pelvis,  on  either  side  of  the 
uterus,  p.  31.  Fig.  15. 

Oviduct  (o'vid-ukt).  The  Fallo- 
pian tube,  which  carries  the  ovum 
from  the  ovary  to  the  uterus.  Fig. 
IS- 

Ovisac  (o'vis-ak).  Graafian  follicle, 
which  see. 

Ovulation  ( o - vu  - la'shun).  The 
formation  and  discharge  of  the  un- 
impregnated ovum  from  the  ovary. 
P-  37- 

Ovule  (o'vul).  The  ovum  within 
the  Graafian  follicle. 

Ovum  (o'vum).  1.  An  egg.  2.  The 
female  reproductive  cell.  The  hu- 
man ovum  is  about  inch  in  diam- 
eter. p.  37. 

Oxytocic  (oks-e-to'sik).  1.  Hasten- 
ing delivery.  2.  A drug  which  hastens 
delivery. 

Ozena  (o-ze'nah).  A disease  of  the 
nose  with  an  offensive  discharge. 

P. 

Pack  the  uterus.  To  tampon  the 
uterus,  p.  220. 

Pallor  (pal'lor).  Paleness ; lack  of 
color,  pp.  273,  277. 

Palpation  (pal-pa'shun).  Exam- 
ination by  the  hand  or  by  the  sense 
of  touch.  Obstetric  p.,  palpation  of 
the  abdomen  of  the  pregnant  woman, 
to  learn  the  size,  position,  and  pres- 
entation of  the  fetus,  p.  173. 

Palpitation  (pal-pit-a'shun).  Un- 
duly rapid  action  of  the  heart. 

Paraplegia  (par  - ah  - pie  ' je  - ah). 
Paralysis  affecting  the  lower  half  of 
the  body.  Paralysis  of  both  legs. 
Usually  associated  with  paralysis  of 
the  lower  half  of  the  trunk. 

Paregoric  (par-e-gor'ik).  Cam- 
phorated tincture  of  opium.  An  ano- 
dyne. Dose,  5-75  min.  for  an  adult. 

Parietal  (par-i'et-al).  Pertaining 
to  the  walls  of  a cavity  or  organ.  P. 
bones,  the  two  large  bones  forming 
| the  sides  and  top  of  the  skull,  p.  44. 


GL  OSSAR  J 


479 


Paroxysm  (par'oks-izm).  A sudden 
recurrence  or  increased  severity  of 
symptoms.  A periodic  attack  of  symp- 
toms. 

Paroxysmal  (par  - oks  - iz  ' mal). 
Having  paroxysms. 

Parturient  (par-tu're-ent).  Child- 
bearing. Giving  birth.  P.  canal, 
the  uterus  and  vagina  considered  as 
one  canal.  P.  woman,  a woman  in 
labor. 

Parturition  (par-tu-rish'un).  The 
process  of  giving  birth  to  a child. 

Pasteur  (pas  - ter').  A noted 
French  physician ; born,  1822;  died, 
1899. 

Pasteurization  (pas  " tur  - iz  - a 

shun).  The  checking  of  fermentation 
(especially  in  milk)  by  heating  to  a 
temperature  of  from  1550  to  170° 
Fahrenheit  for  thirty  minutes. 

Paternal  (pa-ter'nal).  Relating  to 
or  derived  from  the  father. 

Pathologic,  Pathological  (path-o- 
loj'ik,  path-o-loj'ik-al).  Morbid;  dis- 
eased. 

Pathology  (path  - ol ' o - je).  The 
science  which  treats  of  the  nature  of 
disease  and  the  changes  in  the  body 
caused  by  disease. 

Pedunculated  (pe-dung'ku-la-ted) . 
Having  a peduncle  or  stem. 

Pellicle  (pel'ik-l).  A thin  skin  or 
film.  A film  on  the  surface  of  a 
liquid. 

Pelvimeter  (pel-vim'e-ter).  An  in- 
strument for  measuring  the  diameters 
of  the  pelvis,  p.  in. 

Pelvimetry  (pel-vim'et-re).  The 
measurement  of  the  pelvis.  External 
p.,  external  measurements.  Internal 
p.,  internal  measurements,  p.  in. 

Pelvis  (pel' vis).  The  basin-shaped 
ring  of  bone  at  the  lower  extremity  of 
the  trunk.  It  is  formed  in  front  and 
at  the  sides  by  the  innominate  bones, 
and  behind  by  the  sacrum  and  coccyx, 
pp.  21,  26. 

Pemphigus  (pem'fig-us).  An  erup- 
tion on  the  skin  consisting  of  large 
flat  blebs  filled  with  serum  or  pus. 

Pepsin  (pep'sin).  1.  A ferment  of 
the  gastric  juice  which  digests  pro- 
teids.  2.  That  used  as  a medicine  is 
derived  from  the  stomach  of  pigs. 
Dose,  10-15  grains. 

Peptic  salt  ( pep'tik  sawlt).  A com- 


bination of  table  salt  and  scale  pepsin, 
p.  388. 

Perforator  (per'fo-ra-tor).  An  in- 
strument for  piercing  the  bones  of  the 
fetal  head.  Fig.  100. 

Perineorrhaphy  ( per"e-ne-or'ra- 
fe).  The  operation  of  suturing  a tear 
or  laceration  of  the  perineum,  pp. 
129,  218. 

Perineum  (per-e-ne'um).  The 
tissue  between  the  anus  and  vulva. 
P-  32. 

Periphery  (per-if'er-e).  The  cir- 
cumference; the  portion  farthest  from 
the  center. 

Peristalsis  (per-is-tal'sis).  The 
worm-like  movements  by  which  the 
stomach  and  bowels  propel  their 
contents.  It  is  produced  by  the 
contraction  of  the  circular  and  lon- 
gitudinal muscular  fibers  of  these 
organs. 

Peristaltic  (per-is-tal'tik).  Per- 
taining to  peristalsis. 

Peritoneal  (per"it-o-ne'al).  Per- 
taining to  the  peritoneum. 

Peritoneum  (per//it-o-ne'um).  A 
serous  membrane  which  lines  the  ab- 
dominal walls  and  covers  all  the  or- 
gans contained  in  the  abdomen. 

Peritonitis  (per//it-o-ni'tis).  In- 
flammation of  the  peritoneum. 

Pernicious  (per-nish'us)1  Danger- 
ous; tending  toward  a fatal  result. 

Perspiration  (per-spir-a'shun).  1. 
Sweat.  2.  The  function  of  sweat- 
ing. 

Pessary  (pes'sar-e).  An  instru- 
ment placed  in  the  vagina  to  act  as  a 
support  to  the  uterus. 

Phantom  (fan'tum).  An  effigy  of  a 
child  or  mother  used  to  illustrate  the 
mechanism  of  labor.  P.  pregnancy, 
pseudocyesis;  a peculiar  enlargement 
of  the  abdomen  sometimes  occurring 
in  hysterical  women  and  resembling 
the  abdomen  of  a pregnant  woman. 
P.  tumor,  a tumor  of  the  abdomen 
due  to  flatus  or  the  contraction  of 
the  muscles  of  the  abdomen ; phan- 
tom pregnancy. 

Pharmacopeia  t far//mak-o-pe'ah). 
A book  containing  directions  for  pre- 
paring medicines.  Published  by  au- 
thority in  the  United  States  every  ten 
years. 

Phenomenon  (fe-nom'en-on),  pi., 


480 


GLOSSARY 


phenom' ena.  Any  remarkable  ap- 

pearance. Any  sign  or  symptom. 

Phimosis  ifi-mo'sis).  A tightness 
of  the  foreskin  so  that  it  cannot  be 
drawn  back  to  uncover  the  glans  of 
the  penis. 

Phlegmasia  alba  dolens  ( fleg-ma' 
zhe-ah  al'ba  do'lens).  “ Milk  leg.” 
Inflammation  of  the  femoral  vein  oc- 
casionally following  labor  and  typhoid 
fever.  It  is  characterized  by  a pain- 
ful swelling  of  the  leg  without  red- 
ness. p.  297. 

Phlegmatic  (fleg-mat'ik).  Slug- 
gish, heavy,  dull. 

Phlegmon  (fleg'mon).  Inflamma- 
tion of  connective  tissue  with  the  for- 
mation of  an  abscess. 

Physical  (fiz'ik-al).  Pertaining  to 
nature  or  to  the  body. 

Physiologic  (fiz"e-o-loj'ik).  Per- 
taining to  physiology;  normal. 

Physiology  (fiz-  e - ol'o  -je).  The 
science  which  treats  of  the  living  body 
and  its  parts  and  functions. 

Physique  (fi-zek').  Natural  con- 
stitution ; physical  structure  of  a 
person. 

Physometra  (fi-so-me'trah).  Dis- 
tention of  the  uterus  with  gas  or  air. 

Pigment  (pig'ment).  1.  Coloring- 
matter  found  in  organs  and  tissues 
of  the  body.  2.  A dye  or  paint.  A 
paint-like  medicinal  preparation  to 
be  applied  to  the  skin. 

Pigmentary  (pig'men-ta-re).  Per- 
taining to  pigment. 

Pigmentation  (pig-men-ta'shun). 
The  deposit  of  pigment  in  a part. 
The  discoloration  of  a part  by  pig- 
ment. See  Chloasma,  p.  52. 

Pipet  (pi-pet')  [Fr.].  A slender 
glass  tube  used  for  transferring 
liquids. 

Placenta  (pla-sen'tah).  The  after-  ' 
birth ; the  round  flat  organ  in  the 
pregnant  uterus  which  establishes 
communication  between  mother  and 
child,  pp.  42,  46.  P.  prse'via,  a 
placenta  which  is  situated  over  the 
internal  os.  It  may  cause  fatal  hemor- 
rhage. p.  250. 

Pledget  (pled 'jet).  A plug;  a 
sponge ; a small  compress  or  tuft. 
P-  43.3- 

Plethora  (pleth'o-rah,  pleth-o'rah). 
A condition  in  which  there  is  an  ex- 1 


cess  of  blood  in  the  vessels.  It  is  at- 
tended by  a feeling  of  fulness  in  the 
head,  florid  complexion,  and  a ten- 
dency to  nose-bleed. 

Plethoric  (pleth-or'ik,  pleth'or-ik). 
Full-b.ooded. 

Pleura  (piu'rah).  The  serous  mem- 
brane that  lines  the  cavities  of  the 
chest  and  covers  the  lungs. 

Pleural  (plu'ral).  Pertaining  to 
the  pleura. 

Podalic  (po-dal'ik).  Relating  to, 
or  by  means  of,  the  feet.  P.  ver'- 
sion,  the  turning  of  the  child  in  the 
uterus  so  that  the  feet  are  made  to 
present. 

Pole  (pol).  Either  extremity  of  any 
axis. 

Polyhydramnios  ( pol"e-hi-dram'- 
ne-os).  Excessive  amount  of  liquor 
amnii. 

Polyuria(pol-e-u're-ah).  Increased 
urination,  p.  66. 

Position  (po-zish'un).  1.  The  atti- 
tude of  a patient.  2.  The  attitude  of 
the  fetus  in  the  uterus;  the  relation 
which  the  head  of  the  child  bears  to 
the  mother’s  pelvis.  If  the  child’s 
occiput  is  pointing  toward  the  left  side 
of  the  mother,  it  is  a left  position, 
p.  169. 

Posterior  (pos-te're-or).  Situated 
behind  or  to  the  rear. 

Postnatal  (post-na'tal).  Occurring 
after  birth. 

Postpartum  (post-par'tum).  Oc- 
curring after  delivery.  P-p.  chill,  a 
chill  lasting  several  minutes  which 
often  follows  delivery.  P-p.  hemor- 
rhage, hemorrhage  following  deliv- 
ery. p.  272.  P-p.  shock,  the  ex- 
haustion following  labor. 

Postpuerperal  post  - pu  - er ' per- 
al).  Occurring  after  child-birth. 

Precordia  (pre-kor'de-ah).  The 
fore  part  of  the  thorax ; the  region  in 
front  of  the  heart. 

Precordial  (pre-kor'de-al).  Per- 
taining to  the  precordia. 

Pregnancy  (preg'nan-se).  Gesta- 
tion ; the  condition  of  being  with 
child.  The  duration  of  pregnancy  is 
about  2R0  days.  p.  49. 

Pregnant  preg'nant).  With  child; 
gravid. 

Premature  (pre-mat-iir').  Occur- 
ring before  the  proper  time.  P.  in- 


GLOSSARY  481 


fant,  an  infant  born  of  a premature 
labor.  P.  labor,  labor  occurring  from 
the  twenty-eighth  to  the  thirty-eighth 
week  of  pregnancy.  P.  respiration, 
respiration  of  the  child  before  it  is 
completely  born. 

Premonitory  (pre-mon'it-o-re). 
Serving  as  a warning.  P.  pains, 
uterine  pains  occurring  before  the 
beginning  of  true  labor. 

Prepuce  ( pre'pus).  The  foreskin  ; 
the  fold  of  skin  which  covers  the  glans 
penis.  P.  of  the  clitoris,  the  fold  of 
mucous  membrane  which  covers  the 
glans  of  the  clitoris. 

Presentation  (pre  - zen  - ta ' shun). 
That  portion  of  the  fetus  which  occu- 
pies the  lower  segment  of  the  uterus 
and  first  enters  the  birth-canal,  p. 
169. 

Primigravida  (prim-ig-rav'id-ah ) . 
A woman  pregnant  for  the  first  time. 

Primipara  (pri-mip'-ah-rah).  A 
woman  who  is  giving  or  who  has 
given  birth  to  her  first  child. 

Prognosis  (prog-no'sis).  A forecast 
as  to  the  probable  result  of  a disease. 

Prognostic  symptom  (prog-nos'- 
tik  simp'tum).  A symptom  from  which 
a prognosis  may  be  made. 

Prognosticate  (prog  - nos'tik  - at). 
To  make  a prognosis. 

Prolapse  (pro ' laps).  A falling 
down  of  an  organ.  P.  of  the  cord, 
the  descent  of  the  umbilical  cord 
along  with  or  ahead  of  the  presenting 
part  of  the  fetus,  p.  270.  P.  of  the 
uterus,  “ falling  of  the  womb.” 

Promontory  (prom'on-to-re).  A 
projection  or  prominence.  P.  of  the 
sacrum,  the  upper  projecting  part 
of  the  sacrum.  Fig.  1. 

Prophylactic  (pro-fil-ak'tik).  Per- 
taining to  prophylaxis ; preventive. 

Prophylaxis  '(pro-fil-ax'is).  The 
prevention  of  disease ; preventive 
treatment. 

Protargol  (pro-tar'gol).  A soluble 
yellowish  powder;  a preparation  of 
silver.  It  is  a germicide  used  in  gon- 
orrhea and  sore  eyes  and  wounds,  p. 
35i. 

Protein  (pro'te-in).  An  important 
class  of  organic  compounds,  includ- 
ing albumin,  casein,  gluten,  and 
fibrin,  forming  the  important  part  of 
the  tissues  of  the  body.  p.  395. 

31 


Pruritus  (pru-ri'tus).  Intense 
itching,  p.  245. 

Pseudocyesis  (su  " do  - si-e ' sis). 
False  pregnancy ; phantom  tumor, 
p.  74- 

Psychic,  Psychical  (si'kik,  si'kik- 
al).  Pertaining  to  the  mind. 

Psychosis  (si-ko'sis).  Any  disease 
or  disorder  of  the  mind. 

Ptyalism  (ti'al-izm).  Excessive  se- 
cretion of  saliva,  p.  52. 

Puberty  (pu'ber-te).  The  age  at 
which  the  organs  of  reproduction  be- 
come functionally  active,  p.  37. 

Pubes,  Pubis  (pu'bes,  pu'bis).  1. 
The  os  pubis  ; the  pubic  bone.  It  is 
the  anterior  portion  of  the  os  innom- 
inatum,  but  in  fetal  life  it  is  a sepa- 
rate bone.  2.  The  external  part  of 
the  generative  region,  which  is  more 
or  less  covered  with  hair  after  puberty, 
p.  26. 

Pubic  (pu'bik).  Pertaining  to  the 
pubes,  p.  26. 

Pubiotomy  (pu-be-ot'o-me).  Sec- 
tion of  the  os  pubis  at  one  side  of  the 
symphysis  for  the  purpose  of  enlarg- 
ing the  pelvis,  p.  211. 

Pudenda  (pu-den'dah).  Plural  of 
Pudendum,  p.  31. 

Pudendum  (pu-den'dum).  The  ex- 
ternal genitals,  especially  of  the  fe- 
male. p.  31. 

Puerpera  (pu-er'pe-rah).  A woman 
in  child -bed.  p.  61. 

Puerperal  (pu-er'per-al).  Relating 
to  child-bed.  P.  convulsions,  those 
occurring  during  or  immediately  after 
labor.  P.  eclampsia,  same  as  puer- 
peral convulsions.  See  Eclampsia. 
P fever,  fever  due  to  infection  dur- 
ing or  immediately  after  labor;  puer- 
peral infection.  P.  insanity,  P. 
mania,  insanity  developing  in  the 
latest  period  of  pregnancy  or  just 
after  labor.  P.  state,  the  condition 
of  a woman  during  the  ten  days  after 
labor  or  during  the  period  of  con- 
valescence after  labor,  p.  61. 

Puerperium  (pu-er-pe' re-um). 
The  period  or  state  of  confinement 
after  labor,  p.  61. 

Pulmonary  ( pul'mo-na-re).  Per- 
taining to  the  lungs. 

Pulsation  (pul-sa'shun).  A throb 
or  rhythmic  beat,  as  of  the  heart. 

Purpura  (pur'pu-rah).  A disease 


482 


GLOSSARY 


in  which  there  are  purple  patches  1 
on  the  skin  and  mucous  membrane, 
due  to  hemorrhage  under  the  skin. 
There  may  or  may  not  be  fever 
present. 

Purpuric  fpur-pur'ik).  Relating  to 
purpura. 

Purulent  (pu'ru-lent).  Consisting 
of  or  containing  pus. 

Pus  (pus).  A liquid,  the  product 
of  inflammation,  made  up  of  white 
blood-cells  and  a thin  fluid,  which  is 
found  in  abscesses  and  on  the  surface 
of  sores  ; matter  ; corruption. 

Pyosalpinx  (pi-o-sal'pinks).  A col- 
lection of  pus  in  the  Fallopian  tube. 

Pyromania  (pi-ro-ma'ne-ah).  A 
nervous  affection  characterized  by  a 
desire  to  set  fire  to  things. 


Q. 

Quickening.  First  perception  by 
the  mother  of  the  movements  of 
the  child  in  utero.  “Feeling  life’1 
occurs  from  the  fifteenth  to  twentieth 
week. 

R. 

Racemose  (ras'em-os).  Resembling 
a bunch  of  grapes,  p.  35. 

Rachitic  1 rak-it'ik).  Affected  with 
rickets.  R.  pelvis,  a pelvis  deformed 
by  rickets,  p.  27, 

Rachitis  (rak-i'tis).  Rickets. 

Ramus  (ra'mus),  pi.,  ra'mi.  The 
arms  of  the  innominate  bones  which  I 
unite  and  form  the  pubes. 

Rational  (rash'un-al).  1.  Reason- 
able. 2.  Based  on  reasoning.  R. 
symptoms,  subjective  symptoms — 
those  given  by  the  patient. 

Reaction  (re-ak'shun).  1.  Re- 
sponse to  stimulation.  2.  The  phe- 
nomena caused  by  chemicals  acting  j 
upon  one  another. 

Rectal  rek'tal).  Pertaining  to  the 
rectum.  R.  alimentation,  the  ad- 
ministration of  food  by  injecting  it 
into  the  rectum,  p.  459. 

Rectum  (rek'tum).  The  lower  part 
of  the  large  intestine  lying  in  the 
pelvis  and  terminating  at  the  anus.  | 
P-  31- 

Reflex  (re'flex).  1.  Reflected.  2.  | 


A term  applied  to  certain  involuntary 
movements. 

Regurgitation  (re-ger-jit-a'shun> 

1.  A flowing  back.  2.  The  passive 
vomiting  of  infants.  3.  The  return 
of  food  to  the  mouth  unaccompanied 
by  nausea. 

Relaxation  (re-lak-sa'shun).  1. 
Lack  of  muscular  tone  and  strength. 

2.  A lessening  of  tension. 

Remission  (re-mish'unj.  An  abate- 
ment of  symptoms. 

Renal  (re'nal).  Pertaining  to  the 
kidney. 

Respiration  (res-pir-a'shun).  The 
act  of  breathing,  including  inspira- 
tion and  expiration. 

Restitution  (res-tit-u'shun).  The 
rotation  of  the  presenting  part  of  the 
fetus,  outside  the  birth-canal,  so  that 
it  looks  in  the  same  direction  that  it 
did  before  entering  the  pelvis. 

Resuscitation  ( res  - us  - it-a'shun  1. 
The  restoration  to  consciousness  of 
one  who  is  apparently  dead.  p.  362. 

Retained  placenta  (re-tand').  A 
placenta  not  expelled  by  the  uterus 
after  labor. 

Retention  (re-ten'shun).  The  per- 
sistent keeping  within  the  body  of 
matters  that  should  normally  be  ex- 
creted. R.  of  urine,  a condition  in 
which  the  urine  cannot  be  voluntarily 
discharged,  p.  66. 

Rhinitis  (rin'i-tis).  Inflammation 
of  the  mucous  membrane  of  the 
nose. 

Rickets  (rik'ets).  A constitutional 
disease  of  infants  and  young  children 
in  which  there  is  lack  of  earthy  salts 
in  the  bones.  It  results  in  deformi- 
ties and  curvatures  of  the  bones.  It 
is  frequently  due  to  bad  air  and  food. 

Rotation  (ro-ta'shun).  The  act  of 
turning  round  on  an  axis.  R.  stage 
Of  labor,  a movement  in  labor  by 
which  the  occiput  turns  to  the  front 
or  rear.  pp.  24,  25. 

Rupture  (rup'tur).  1,  A forcible 
tearing  of  a part.  2.  A hernia,  p. 
358. 


S. 

Saccharum  lactis  (sak'ar-um  lak- 
tis).  Sugar  of  milk.  p.  397. 

Sacro-anterior  (sa"kro-an-te're- 


GLOSSARY 


483 


or).  Having  the  sacrum  pointing  to  I 
the  front,  pp.  171,  172. 

Sacro-posterior  (sa^kro-pos-te'- 
re-or).  Having  the  sacrum  pointing 
to  the  back.  pp.  171,  172. 

Sacrum  (sa'krum).  The  triangu- 
lar bone  which  forms  the  back  of  the 
pelvis.  Above,  it  articulates  with  the 
spinal  column,  and  below  with  the 
coccyx.  It  is  formed  by  the  fusion 
of  the  five  sacral  vertebrae,  p.  22. 

Sagittal  (saj'it-tal).  Shaped  like  an 
arrow.  S.  suture,  the  suture  between 
the  two  parietal  bones,  pp.  43,  44. 

Saliva  (sal-i'vah).  Spittle;  the 
clear,  viscid,  alkaline  digestive  fluid 
secreted  by  the  salivary  glands  in  the 
mouth.  It  contains  a ferment,  ptyalin, 
which  converts  starch  into  maltose. 

Salivation  (sal-iv-a'shun).  An  ex- 
cessive flow  of  saliva;  ptyalism.  pp. 
52,  45°- 

Saturated  solution  (satsh  ' er-a- 
ted).  A solution  which  will  not 
contain  any  more  of  a given  sub- 
stance. 

Scalpel  (skal'pel).  A small  straight 
knife  with  a convex  cutting  edge. 

Scapula  (skap'u-lah).  The  shoul- 
der-blade. 

Scopolamin  (sko-pol-am'in).  A 
new  drug  derived  from  the  scopolo- 
mina  japonica,  often  used  in  combi- 
nation with  morphine  for  the  produc- 
tion of  anesthesia,  p.  120. 

Scrotum  (skro'tum).  The  pouch  j 
which  contains  the  testicles. 

Sebaceous  (se-ba'shus).  1.  Pertain- 
ing to  sebum  or  fat.  2.  Secreting  a 
greasy  substance  or  sebum. 

Sebum  (se'bum).  A thick,  semi- 
liquid substance,  composed  of  fat  and 
broken-down  epithelial  cells,  which 
is  discharged  upon  the  skin. 

Secretion  (se-kre'shun).  1.  The 
process  of  separating  various  sub- 
stances from  the  blood.  2.  Any  se- 
creted substance. 

Secundines  (se-kun'dinz).  The  j 
after-birth  and  membranes,  pp.  40,  46. 

Segmentation  (seg-men-ta'shun). 
The  division  into  parts,  more  or  less 
similar,  especially  that  which  takes 
place  in  the  fertilized  ovum. 

Semen  (se'men).  1.  A seed.  2.  j 
The  fluid  secreted  by  the  male  gen- 
erative organs. 


Semilunar  (sem-il-u'nar).  Shaped 
like  a crescent. 

Sepsis  (sep'sis).  Infection  by  bac- 
teria. p.  279. 

Septic  (sep'tik).  Produced  by  or 
due  to  infection. 

Serous  (se'rus).  Having  the  nature 
of  serum. 

Serum  (se'rum).  The  clear,  straw- 
colored  liquid  which,  in  the  clotting 
of  blood,  separates  from  the  clot  and 
corpuscles. 

Shock  (shok).  Sudden  depression 
of  the  vital  powers  due  to  an  injury 
or  powerful  emotion.  That  due  to 
injury  is  surgical  shock;  that  due  to 
emotion  is  mental  shock. 

Show  (sho).  1.  The  blood-tinged 
discharge  of  mucus  from  the  cervix 
preceding  labor,  p.  57.  2.  The  vag- 
inal discharge  of  menstruation. 

Sigmundine,  Justine  isig-mun'- 
den).  A midwife  who  lived  in  the 
seventeenth  century. 

Sims,  J.  Marion  (simz).  A noted 
American  gynecologist  who  lived  in 
the  nineteenth  century.  S.  position, 
the  patient  lies  on  the  left  side,  and  the 
chest,  the  right  knee,  and  thigh  well 
drawn  up,  the  left  arm  along  the  back 
or  over  the  edge  of  the  table,  p.  270. 
S’s  speculum,  a vaginal  speculum 
or  retractor. 

Siphon,  Syphon  (si'fon).  A bent 
tube  by  which  liquid  may  be  trans- 
ferred from  one  vessel  to  another  over 
an  intervening  elevation.  Fig.  199. 

Skim  milk  (skim  milk).  Milk  from 
which  the  cream  has  been  removed ; 
it  contains  from  1 to  2 per  cent.  fat. 
P-  398- 

Smegma  1 smeg'mah).  The  secre- 
tion of  the  sebaceous  glands  under 
the  prepuce  and  around  the  labia 
minora,  p.  109.  S.  embryo'num, 
vernix  caseosa.  (Rare.) 

Soda-bicarbonate.  Baking  soda. 
Dose,  5-30  grains,  p.  432. 

Soda-carbonate.  Washing  soda. 

Solution  (so-lu'shun).  1.  The  pro- 
cess of  dissolving.  2.  A liquid  con- 
taining dissolved  matter. 

Sordes  (sor'dez).  The  foul  matter 
which  collects  on  the  lips  and  teeth 
in  typhoid  and  other  fevers  and  con- 
ditions. 

Sound  (sownd).  An  instrument  to 


484 


GLOSSARY 


be  introduced  into  a cavity  to  detect 
a foreign  body  or  dilate  a stricture. 

Spastic  (spas'tik).  A term  applied 
to  muscle  that  is  rigidly  contracted. 

Specific  (spe-sif'ik).  1.  Pertaining 
to  species.  2.  Produced  by  a single 
kind  of  organism.  3.  A remedy  which 
has  a peculiar  efficiency  in  a certain 
disease.  S.  disease.  1.  A disease 
produced  by  a specific  cause.  2.  The 
term  is  sometimes  restricted  to  syph- 
ilis. p.  449.  S.  gravity,  the  weight 
of  a substance  compared  with  an 
equal  volume  of  another  substance 
taken  as  a standard.  Hydrogen  is 
the  standard  for  gases  and  distilled 
water  for  liquids. 

Spermatozoid  (sper-mat-o-zo'id). 
Same  as  Spermatozoon. 

Spermatozoon  (sper-mat-o-zo'on). 
pi.,  spermatozoa.  The  motile,  micro- 
scopic, sexual  element  of  the  semen 
— the  male  element  of  fertilization. 

Spir'itus  Athens  Nitro^si. 
Sweet  sp  rits  of  niter;  dose,  3%SY 
S.  frumen'ti,  whisky. 

Sprue  (sproo).  Thrush  ; a sore 
mouth  of  infants,  with  the  formation 
of  whitish  patches  and  superficial 
ulcers,  p.  333. 

Stasis  (sta'sis).  Stagnation  ; non- 
movement : usually  applied  to  fluids. 

Sterile  (ster'il).  1.  Barren.  2. 
Not  containing  micro-organisms ; 
aseptic ; surgically  clean. 

Sterility  (ster-il'it-e).  The  con- 
dition of  being  barren.  Inability  to 
become  pregnant. 

Sterilization  (ster  - il  - iz  - a'shun). 
The  process  of  rendering  an  object 
free  from  germs,  p.  92. 

Sterilizer  ister'il-i-zer).  An  appa- 
ratus for  sterilizing,  p.  430. 

Still-born.  Born  dead.  p.  360. 

Stimulant  (stim'u-lant).  1.  Stimu- 
lating. 2.  A medicine  which  pro- 
duces stimulation. 

Stimulate  (stim'u-lat).  To  excite 
to  functional  activity. 

Stimulus  (stim'u-lus).  An  agent 
that  excites  to  functional  activity. 

Stool  (stool).  The  feces  discharged 
from  the  bowels. 

Streptococcus  (strep-to-kok'us). 
A variety  of  micro-organisms.  It 
causes  the  severest  child-bed  infec- 
tions. 


Stria  (stri'ah),  pi.,  stri'ce.  A streak 
or  line.  S.  gravida'rum,  the  striae 
seen  on  the  abdomen  of  women  who 
are  or  have  been  pregnant.  See 
Linea  albicantes.  pp.  51,  52. 

Strophulus  ( strof'u-lus).  An  erup- 
tion of  infants  called  "tooth-rash" 
or  “ gum-rash.”  p.  342. 

Stupor  (stu'por).  Unconscious- 
ness, partial  or  complete. 

Styptic  (stip'tik).  1.  Astringent. 
2.  A remedy  that  is  markedly  astrin- 
gent and  hemostatic. 

Subcutaneous  (sub-ku-ta'ne-us). 
Under  the  skin.  S.  injection.  See 
Hypodermic  injection. 

Succedaneum  (suk-se-da'ne-um  i. 
A medicine  that  may  be  substituted 
for  another  of  like  properties.  Caput 
s.,  a dropsical  swelling  on  the  pre- 
senting part  of  the  fetal  head  during 
labor,  due  to  lack  of  pressure  on  the 
part  and  pressure  on  the  surrounding 
area.  p.  356. 

Superior  strait  (su-pe're-or).  The 
upper  border  of  the  true  pelvis ; the 
inlet ; the  brim.  p.  24. 

Suppository  (sup-oz'it-o-re).  An 
easily  fusible  medicated  mass  intro- 
duced into  the  rectum,  urethra,  or 
vagina. 

Suppuration  (sup-u-ra'shun).  The 
formation  of  pus. 

Suppurative  (sup'u-ra-tiv).  Pro- 
ducing or  discharging  pus. 

Suture  (su'tur).  1.  A surgical  stitch 
or  seam.  p.  129.  2.  The  material 

used  for  a suture.  3.  The  line  of 
union  between  two  bones  of  the  head 
or  face.  pp.  43,  44. 

Symphysiotomy  (sim-fiz-e-ot'o- 
me).  The  operation  of  severing  the 
ligaments  and  cartilage  forming  the 
pubic  joint  or  symphysis.  Done  in 
difficult  labor,  p.  211. 

Symphysis  1 sim'fiz-is).  1.  A kind 
of  firm  joint.  2.  The  term  is  used  to 
refer  to  the  symphysis  pubis  or  union 
between  the  two  pubic  bones,  p.  26. 

Synchondrosis  (sin-kon-dro'sis). 
The  union  of  bones  by  means  of  elas- 
tic cartilage. 

Syncope  (sin'ko-pe).  Fainting;  a 
swoon  ; a more  or  less  complete  sud- 
den failure  of  respiration  and  heart 
action,  p.  273. 

Syphilis  (sif'il-is).  An  infectious 


GLOSSARY  485 


disease,  usually  venereal  in  origin, 
very  chronic  and  obstinate  in  nature, 
p.  449. 

T. 

Tampon  (tam'pon).  1.  A plug  of 
cotton,  gauze,  or  other  material, 
placed  in  a cavity  to  stop  a hemor- 
rhage or  absorb  secretions.  2.  To 
place  a tampon,  p.  220. 

Tamponade,  Tamponage  (tam'- 
pon-ad,  tam'pon-aj).  The  use  of  the 
tampon,  p.  220. 

Tamponing  (tam'pon-ing).  The 
act  of  using  the  tampon,  p.  220. 

T-bandage.  A bandage  shaped 
like  the  letter  T ; used  to  retain  dress- 
ings of  the  vulva  in  place,  p.  92. 

Tenaculum  (ten-ak'u-lum).  A 
hook-shaped  instrument;  ahook.  T. 
forceps,  a forceps  armed  with  hooks  ; 
a volsella.  p.  195. 

Tenesmus  (ten-es'mus).  Straining ; 
ineffectual  straining  at  stool  or  at 
urination;  a feeling  of  desire  to  strain 
at  stool,  etc. 

Testicle  (tes'tik-l).  One  of  the  two 
male  organs  in  the  scrotum,  analo- 
gous to  the  ovary  in  women. 

Tetanus  (tet'an-us).  Lockjaw;  a 
disease  caused  by  the  bacillus  of  tet- 
anus, and  in  which  there  are  tonic 
spasms  of  some  of  the  voluntary  mus- 
cles, first  noticed  in  the  muscles  of  I 
jaw  and  throat. 

Thermostat  (ther'mo-stat).  An 
apparatus  for  automatically  regulat- 
ing heat.  p.  368. 

Thoracic  (tho-ras'ik).  Pertaining 
to  the  thorax. 

Thorax  (tho'raks).  The  part  of  the 
body  above  the  diaphragm.  It  con- 
tains the  heart  and  lungs. 

Thrombosis  (throin'bo-sis).  The 
formation  of  a thrombus  or  clot  in  a 
vessel,  p.  297. 

Thrombotic  (throm-bot'ik).  Per- 
taining to  or  of  the  nature  of  a throm- 
bus. p.  297. 

Thrombus  (throm'bus).  A clot  in 
a blood-vessel  remaining  at  the  point 
of  its  formation. 

Thrush  (thrush).  Sore  mouth; 
sprue.  Caused  by  a vegetable  fungus 
called  Monilia  albicans,  pp.  333,  388. 

Tissue  ( tish'u).  An  aggregation  of 


[ cells  forming  a structure  with  a defi- 
nite function. 

Torsion  (tor'shun).  Twisting.  T. 
of  the  umbilical  cord,  the  spontane- 
ous twisting  of  the  cord  in  uiero. 

Toxemia  (tok-se'me-ah).  A condi- 
tion due  to  the  presence  of  toxins  in 
the  blood.  These  toxins  may  be  the 
product  of  bacterial  action,  or  they 
may  be  effete  matter  which  should  be 
excreted,  pp.  87,  242. 

Trachea  (tra'ke-ah).  The  wind- 
pipe ; the  air-tube  leading  from  the 
larynx  to  the  bronchi. 

Tracheal  catheter  ( tra'ke-al).  A 
slender  tube  or  catheter  for  drawing 
mucus  and  fluids  from  the  trachea  in 
case  of  asphyxiation,  and  blowing  air 
into  the  lungs,  p.  360. 

Traction  (trak'shun).  The  act  of 
drawing  or  pulling. 

Transfusion  (trans-fu' shun).  1. 
The  transfer  of  blood  from  one  per- 
son to  another.  2.  The  introduction 
into  the  blood-vessels  of  any  liquid, 
as  salt  solution,  p.  225. 

Trendelenburg  position  (tren'- 
del-en-berg).  The  patient  lies  flat  on 
the  back.  The  end  of  the  table  is 
elevated  so  that  the  hips  are  raised  to 
an  angle  of  450.  The  legs  hang  over 
the  end  of  the  table.  Used  in  ab- 
dominal operations  and  in  the  treat- 
ment of  prolapse  of  the  cord.  p.  271. 

Tubercle  (tu'ber-kl).  A rounded 
nodule  or  elevation. 

Tuberculosis  (tu-ber-ku-lo'sis). 
An  infectious  disease  caused  by  tu- 
bercle bacilli,  and  characterized  by 
the  formation  of  tubercles.  In  the 
lungs  it  is  called  consumption. 

Tumor  (tu'mor).  1.  A swelling.  2. 
A new  growth ; a tissue  which  grows 
independent  of  surrounding  struc- 
tures and  has  no  physiologic  use. 
A tumor  which  tends  to  recur  after 
removal  is  malignant ; one  which  does 
not  is  benign. 

Tympanites  (tim-pan-i'tez).  Dis- 
tention of  the  bowels  or  peritoneal 
cavity  with  air  or  gases.  p.  299. 
Uterine  t.,  distention  of  the  uterus 
with  gas.  Phvsometra. 

Typhoid  fever  (ti'foid).  A spe- 
cific fever  due  to  the  Bacillus  typhosus, 
and  following  a particular  course  T. 
state,  a condition  of  great  physical 


486 


GLOSSARY 


exhaustion,  with  stupor  and  delirium, 
resembling  that  found  about  the  close 
of  the  second  week  of  typhoid.  It 
may  occur  in  toxemia  and  puerperal 
infection. 

U. 

Ulcer  (ul'ser).  An  open  sore. 

Ulcerate  (ul'ser-at).  To  form  an 
ulcer;  to  be  affected  with  ulcers. 

Umbilical  (um-bil'ik-al).  Pertain- 
ing to  the  umbilicus  or  navel.  U. 
arteries,  the  arteries  forming  part  of 
the  umbilical  cord.  U.  cord,  the  cord 
connecting  the  placenta  with  the  um- 
bilicus of  the  fetus.  It  is  made  up  of 
the  umbilical  arteries  and  veins  and  a 
jelly-like  substance  called  “ Whar- 
ton’s jelly.”  p.  43.  U.  hernia,  her- 
nia at  the  navel.  U.  veins,  the  veins 
of  the  umbilical  cord. 

Umbilicus  (um  - bil  - i 'kus).  The 
navel ; the  site  of  entrance  of  the 
umbilical  vessels  into  the  abdomen, 
p.  346. 

Urea  (u-re'ah).  The  principal  solid 
of  the  urine  ; it  carries  off  most  of  the 
waste  nitrogenous  products  of  the 
body. 

Uremia  (u-re'me-ah).  The  toxic 
condition  produced  by  the  presence 
of  urinary  constituents  in  the  blood. 
It  is  due  to  diminution  of  excretion 
by  way  of  the  urine  and  is  marked 
by  nausea,  vomiting,  dizziness,  head- 
ache, and  coma. 

Uremic  (u-re'mik).  Affected  with 
uremia. 

Urethra  (u-re'thrah).  The  mem- 
branous canal  leading  from  the  blad- 
der to  the  surface  of  the  body.  p.  31. 

Urethral  ( u-re'thral).  Pertaining 
to  the  urethra,  p.  31. 

Uric  acid  (u'rik).  A crystallizable 
acid  found  in  urine.  It  is  nearly  in- 
soluble, and  when  retained  in  the 
system  is  thought  to  produce  gout 
and  rheumatism. 

Urinal  (u'rin-al).  A vessel  to  re- 
ceive urine.  1 

Urinalysis  (u  - rin  - al'is  - is).  The 
analysis  of  urine. 

Urinary  (u'rin-a-re).  Pertaining  to 
urine. 

Urinate  (u'rin-at).  To  pass  urine 
from  the  bladder. 


Urination  (u-rin-a'shun).  The  act 
of  passing  the  urine  from  the  bladder. 

Urine  ( u'rin).  The  fluid  secreted 
by  the  kidneys,  stored  in  the  bladder, 
and  discharged  through  the  urethra. 
Incontinence  of  u.,  inability  to  re- 
tain urine  in  the  bladder,  so  that  it 
escapes  involuntarily  ; incontinentia 
paradoxa,  filling  of  the  bladder,  with 
overflow  and  dribbling  away  of  urine. 
Retention  of  u.,  inability  to  pass  the 
urine.  Suppression  of  u.,  arrested 
secretion  of  urine  by  the  kidneys. 

Urinometer  ( u-rin-om'et-er).  An 
instrument  for  determining  the  spe- 
cific gravity  of  urine. 

Uterine  (u'ter-in).  Pertaining  to 
the  uterus  or  womb.  U.  appendages, 
the  Fallopian  tubes  and  the  ovaries. 
U.  atony,  weakness  of  the  uterine 
muscle  ; term  used  during  and  after 
labor.  U.  colic,  pains  in  the  uterus 
from  any  cause  except  labor  pains. 
U.  gestation,  normal  pregnancy  U. 
inertia,  lack  of  contractile  power 
of  the  uterus  during  labor : ‘ ‘ weak 
pains  atony.  U.  involution,  the 
process  by  which  the  uterus  regains 
its  ordinary  size  and  shape  after  labor. 
U.  mole,  a mass  in  the  uterus  con- 
sisting of  a dead  fetus  and  its  envel- 
opes. U.  phlebitis,  a form  of  puer- 
peral fever.  U.  pregnancy,  normal 
pregnancy.  U.  probe,  a long,  flexi- 
ble probe  for  exploring  the  uterus. 
U.  sinuses,  the  veins  of  the  uterus 
enlarged  by  pregnancy.  U.  sound, 
a uterine  probe.  U.  tubes,  Fallopian 
tubes,  U.  wound,  the  area  from 
which  the  placenta  has  been  re- 
moved. 

Uterus  (u'ter-us).  The  womb;  the 
hollow  muscular  organ  in  which  the 
fetus  is  normally  developed,  p.  28. 

V. 

Vagina  (vaj-i'nah).  The  curved 
canal  extending  from  the  cervix  of  the 
uterus  to  the  vulva,  pp.  29,  64. 

Vaginal  (vaj'in-al).  Pertaining  to 
the  vagina.  V.  examination,  exam- 
ination of  the  pelvic  organs  by  means 
of  the  finger  introduced  into  the  vag- 
ina. V.  speculum,  an  instrument 
for  holding  the  vagina  open  in  order 
that  its  interior  may  be  inspected. 


GLOSSARY  487 


Valance  (val'anz).  Hanging  dra- 
pery about  a bedstead,  p.  107. 

Varicose  (var'ik-5s).  1.  Unnatur- 
ally swollen  or  dilated ; a term  ap- 
plied to  veins.  2.  Pertaining  to  a 
varix.  p.  243. 

Varicosity  (var-ik-os'it-e).  1.  A 
varicose  condition  of  the  veins.  2.  A 
varix.  p.  243. 

Varix  (va'rix).  An  enlarged  tortu- 
ous vein.  p.  243. 

Vascular  ( vas ' ku  - lar).  Having 
blood-vessels ; full  of  blood-vessels. 

Vascularity  (vas-ku-lar'it-e).  The 
condition  of  being  vascular. 

Vectis  (vek ' tis).  A curved  lever 
for  making  traction  on  the  fetal  head 
during  labor  ; almost  obsolete  now. 

Vein  (van).  A blood-vessel  carry- 
ing blood  to  the  heart. 

Venous  (ve'nus).  1.  Pertaining  to 
the  veins.  2.  Contained  in  the  veins. 
V.  blood,  the  dark-colored  blood  | 
collected  from  the  tissues  and  carried 
by  the  veins  to  the  heart.  It  is  dark 
from  the  lack  of  oxygen  and  the  pres- 
ence of  carbon  dioxid.  V.  circula- 
tion, the  circulation  of  blood  through 
the  veins.  V.  congestion,  the  en- 
gorgement of  an  organ  with  venous 
blood,  due  to  an  obstruction  to  its 
return  to  the  heart. 

Vernix  caseosa  (ver'nix  ka-se-o'- 
sah).  “ Cheesy  varnish.”  The  greasy 
substance  which  covers  the  skin  of 
the  fetus,  p.  69. 

Version  ( ver'shun).  1.  The  act  of 
turning.  2.  The  turning  of  the  fetus 
in  utero  by  the  obstetrician  to  facili- 
tate delivery,  p.  197. 

Vertebra  i ver'te-brah).  Any  one 
of  the  thirty-three  bones  of  the  spinal 
column. 

Vertex  (ver'tex).  1.  Head.  2.  The 
crown  of  the  head.  V.  presentation, 
the  presentation  of  the  top  of  the  fetal 
head  in  labor,  pp.  171,  172. 

Vertigo  (ver'tig-o).  Dizziness; 
giddiness;  “swimming  of  the  head.” 

Vesical  (ves'ik-al).  Pertaining  to 
the  bladder. 

Vesicle  (ves'ik-l).  1.  A small  blad- 
der or  sac  containing  liquid.  2.  A 
small  blister  on  the  skin  or  mucous 
membrane,  p.  342. 

Vesicular  (ves-ik'u-lar).  1.  Com- 
posed of  small,  sac-like  bodies.  2. 


Composed  of  vesicles  or  blisters  on 
the  skin.  p.  342. 

Vestibule  (ves'tib-ul).  1.  The  oval 
cavity  of  the  internal  ear.  2.  The 
space  between  the  labia  minora,  be- 
low the  clitoris,  just  above  the  en- 
trance to  the  vagina,  p.  33. 

Viability  (vi-ab-il'it-e).  Ability  to 
live.  p.  365. 

Viable  (vi'ab-1).  Able  or  likely  to 
live  outside  the  uterus.  Said  of  a 
fetus  that  is  sufficiently  developed  to 
live  outside  the  uterus,  p.  365. 

Villus  (vil'us),  pi.,  vil'li.  1.  One 
of  the  small  vascular  projections  of 
the  placenta  which  help  attach  it  to 
the  wall  of  the  uterus  and  through 
which  the  nourishment  of  the  child  is 
provided,  pp.  41,  46.  2.  One  of  the 

club-shaped  projections  from  the  mu- 
cous membrane  of  the  intestines. 

Virulent  (vir'u-lent).  Exceedingly 
| poisonous  or  harmful ; having  the 
nature  of  virus. 

Virus  (vi'rus).  1.  Any  animal 
poison.  2.  Especially  that  poison 
which  is  produced  by  and  able  to  im- 
part disease.  The  poison  is  due  to 
the  presence  of  disease-producing  or- 
ganisms or  fluids. 

Viscus  (vis'kus),  pi.,  vis'cera.  Any 
organ  contained  within  the  cavities 
of  the  body,  especially  the  abdomen. 

Visual  (viz  ' u - al).  Pertaining  to 
vision  or  sight. 

Vital  (vi'tal).  Essential  to  life. 
Pertaining  to  life. 

Vitality  (vi  - tal ' it  - e).  The  vital 
principle.  The  vital  power. 

Volsella,  Volsellum,  (vol-sel'ah, 
vol-sel'um).  A forceps  the  ends  of 
whose  blades  are  furnished  with 
sharp  hooks,  p.  195. 

Vulsella,  Vulseilum  (vul-sel'ah). 
Same  as  Volsella.  p.  195. 

Vulva  (vul  ' vah  ).  The  external 
genitals  of  the  female,  pp.  29,  32. 

W. 

Walcher’s  position  (val'tsher). 
The  patient  lies  on  her  back  with  the 
buttocks  raised  and  well  over  the 
table,  the  legs  hanging  down.  In 
this  position  the  true  conjugate  diam- 
eter of  the  pelvis  is  increased  nearly 
half  an  inch.  p.  195. 


488 


GLOSSARY 


Wassermann  reaction.  A test 
of  the  blood  which  shows  the  presence 
of  syphilis,  p.  450. 

Wet-nurse  (wet-nurs).  A woman 
who  suckles  the  child  of  another, 
p.  326. 

Wharton’s  gelatin,  Wharton’s 
jelly  (whar'tonzj.  The  jelly-like 
tissue  which  makes  up  the  greater 
part  of  the  umbilical  cord. 


Whites  (whitz).  Leukorrhea. 

Winckel’s  disease  (wink'lz).  An 
extremely  fatal  disease  in  the  new- 
born, marked  by  jaundice,  bloody 
urine,  hemorrhage,  and  cyanosis. 
Malignant  jaundice. 

Witches’  milk  (witsh'ez).  The 
milky  fluid  secreted  by  the  breast  of 
the  new-born.  p.  344. 

Womb  (woom).  The  uterus,  p.  28. 


INDEX 


Abdomen,  pains  in,  in  pregnancy, 
247 

pendulous,  in  pregnancy,  246 
Abdominal  supporter  in  pregnancy, 
76 

Kabo,  77 
Ablactation,  326 
Abnormal  milk,  325 
Abnormalities  of  nipples,  312 
Abortion,  55,  249 

instruments  for  treatment  of,  234 
therapeutic,  234 
Abruptio  placentae,  251 
Abscess,  sub  mammary,  316 
Accidents,  prevention  of,  421 
Acid,  boric,  solution  of,  444 
carbolic,  solution  of,  443 
uric,  in  urine,  338 
Acini  of  breast,  35 
After-birth.  See  Placenta. 
After-pains,  61,  299 
Agalactia,  321 

Bier’s  treatment  in,  323 
causes,  322 
electricity  in,  324 
massage  of  breasts  in,  323 
pituitrin  in,  322 
symptoms,  322 
thyroid  extract  in,  322 
treatment,  322 

Ahlfeld’s  method  of  sterilization  of 
hands,  425 
Air  pessary,  231 


Air-embolism,  128 

in  third  stage  of  labor,  128 
Albumin,  453 
Albuminuria,  86 
Alcohol  in  pregnancy,  81 
Ambulance,  incubator,  372,  373 
Anesthesia,  188 

in  second  stage  of  labor,  1 23 
Anesthetic  in  cesarean  section,  207 
Ankyloglossia,  357 
Anus,  31,  34 
imperforate,  357 
occlusion  of,  357 
Apartments,  sterilization  of,  440 
Aphthae,  Bednar’s,  334 
Applicators,  95,  135 
Aprons,  sterilization  of,  440 
Areola  of  pregnancy,  36 
Areolar  signs  in  diagnosis  of  preg- 
nancy, 73 

Argyrol  in  prevention  of  ophthal- 
mia neonatorum,  133 
Artificial  infant  foods,  408 
respiration,  362 

Byrd’s  method,  362 

De  Lee’s  modification, 
362,  363 

Sylvester’s  method,  363 
Asepsis  of  breasts  during  puerpe- 
rium,  286 

of  nurse  during  puerperium,  285 
Asphyxia  livida,  360 
neonatorum,  360 


489 


490 


INDEX 


Asphyxia  neonatorum,  treatment, 
360 

pallida,  360 
Atelectasis,  189,  337 
pulmonum,  68 

of  premature  infants,  390 
Auto-infection,  283 
Auvard  incubator,  368 
Axis- traction  forceps,  19 1 

Bag  of  waters,  59 
Balloon  dilators,  231 
Bands,  infant’s,  97 
Baptism  of  child,  200 
Barley-water,  407,  453 
Barnes’  bag,  231 
Basins,  sterilization  of,  439 
Bath,  Winckel’s  permanent,  for 
premature  infants,  367 
Bathing  infant,  151 
in  pregnancy,  87 
in  puerperium,  147 
of  premature  infant,  384 
Bearing-down  pains,  59 
Bed  of  incubator,  375 
of  newborn  infant,  100 
preparation  of,  for  first  stage  of 
labor,  107 

symphysiotomy,  216 
Bed-frame,  symphysiotomy,  215 
Bednar’s  aphthae,  334 
Bed-pans,  sterilization  of,  439 
Bed-sores,  prevention  of,  in  preg- 
nancy, 242 

Beef,  digested,  by  rectum,  460 
Beef-juice,  408,  453 
Beef-tea,  453 
with  acid,  453 
Belt,  Momburg’s,  276 
Bichlorid  of  mercury  solutions, 
preparation  of,  442 


Bier’s  method  of  treating  mastitis, 
320 

treatment  in  agalactia,  323 
Bifid  nipple,  312 
Binder,  breast-,  93 
applied,  308 
long,  138 
T-,  92 

Birth  certificate,  134 
Birth-mark,  83 
Bladder,  31 
anatom)'-  of,  31 
in  puerperium,  145 
inflammation  of,  in  puerperium, 
303 

Blankets,  infant’s,  97 
Blisters  of  nipple,  313 
water-,  342 

Blood  in  pregnancy,  50 
Blue  babies,  68,  367,  390 

spells  of  premature  infants,  389 
Bones,  innominate,  23 
Borborygmus,  157,  328 
Boric  acid  solution,  444 
Bottle,  nursing,  for  premature  in- 
fants, 380 

Bottles,  filling  of,  403 
Bowels  in  pregnancy,  84 
in  puerperium,  67,  144 
of  newborn  infant,  70,  156 
Brain,  injuries  to,  in  birth,  355 
Braun’s  colpeurynter,  231 
cranioclast,  198 
decapitation  hook,  198 
Breast,  acini  of,  35 
anatomy  of,  35 

asepsis  of,  during  puerperium, 
286 

care  of,  during  puerperium,  135 
diseases  of,  307 

engorgement  of,  in  puerperium 
6S,  i45,  307 


INDEX 


49 1 


Breast,  enlargement  of,  as  sign  of 
pregnancy,  73 
in  newborn,  344 
in  pregnancy,  50 
care  of,  77,  89 
in  puerperium,  65 
inflammation  of,  315 
massage  of,  309-231 
in  agalactia,  323 
tray  and  contents,  137 
Breast-binder,  93 
applied,  308 
Breast-pump,  163 
Breech  delivery,  forceps  in,  196 
mechanism  of,  177 
presentation,  177,  269 
Brim  of  pelvis,  24 
Broad  ligaments,  31 
Bronchitis,  336 
Broth,  chicken,  454 
clam,  454 
mutton,  457 

Brushes,  sterilization  of,  433 
Bumm’s  pubiotomy  needle,  212 
Byrd’s  method  of  artificial  respira- 
tion, 362 

De  Lee’s  modification, 
362,  363 

Caloric  method  of  feeding,  402 
Cannula,  glass,  for  intravenous 
transfusion,  226 
Caput  succedaneum,  356 
Carbolic  acid  solution,  443 
Castor  oil,  administration  of,  144 
Catgut,  sterilization  of,  439 
Catheter,  tracheal,  360 
Catheterization  after  pubiotomy, 
217 

in  puerperium,  146 
Caul,  60 

Cephalhematoma,  356 


I Cephalotripsy,  198 
Cereal  extract,  454 
Certified  milk,  405 
I Cervix  uteri,  28 
Cesarean  section,  201 
after-care,  209 
arrangement  of  room,  204 
convalescence,  210 
instruments  for,  206 
light,  heat,  and  anesthetic,  207 
list  of  supplies  needed  for,  205 
operation,  208 
preparation  for,  203 
steps  of,  203,  209 
vaginal,  210 
Chafe,  159 
Chafing,  343 
treatment,  343 
Champagne  whey,  454 
Champetier  de  Ribes’  bag,  231 
Chicago  Lying-in  Hospital,  diet 
table  at,  378 
incubator  station,  369 
Chicken  broth,  454 
Child,  care  of,  151 

overgrowth  of,  diet  for  preven- 
tion of,  452 
Chinosol,  443 

Chloral  in  second  stage  of  labor,  1 20 
Circumcision,  338 
Clam  broth,  454 
Cleft  palate,  356 

nipple  for  babies  with,  356 
Clitoris,  32 
Coccyx,  22 

Coffee,  nutritious,  457 
I Colic,  329 
Colostrum,  50,  65 
Colpeurynter,  Braun’s,  231 
Composition  of  milk,  395 
Conception,  40 
Congenital  deformities,  356 


49  2 


INDEX 


Conjunctivitis  in  infant,  treatment 

of,  155 

Constipation  in  infant,  1 56,  330 
in  pregnancy,  54 
in  puerperium,  300 
Contracted  pelvis,  27 
Convulsions,  358 
in  pregnancy,  256 
in  premature  infant,  390 
Cord.  See  Umbilical  cord. 
Coronary  suture,  43 
Corsets  after  delivery,  150 
in  pregnancy,  76 

high  stomach  from,  75 
Coryza,  336 

Couveuse,  368.  See  also  Incuba- 
tor. 

Covered  sponges,  433 
Cracks  of  nipple,  313 
Cramp  in  leg  during  second  stage 
of  labor,  119 
Cranioclasis,  198 
Cranioclast,  Braun’s,  198 
Craniotomy,  198 

Crede’s  method  for  prevention  of 
ophthalmia  neonatorum,  132 
Creolin,  443 
Cross-birth,  177,  197 
Curettage,  uterine,  224 
Cyanosis,  337 
in  premature  infants,  389 
Cystitis  in  puerperium,  303 

De  Lee’s  glove  sterilizer,  428 
long  uterine  packing  forceps,  220 
method  of  sterilization  of  hands, 
426 

of  rubber  gloves,  427 
modification  of  Byrd’s  method  of 
artificial  respiration,  362,  363 
needle  for  hypodermoclysis,  225 
Decapitation,  197 


Decapitation  hook,  Braun’s,  198 
Decubitus  in  pregnancy,  prevention 
of,  242 

Deformed  pelves,  27 
Deformities,  congenital,  356 
Delayed  separation  of  cord,  345 
urination,  337 
Deportment  of  nurse,  446 
Destitute,  care  during  labor  among, 
411 

Detachment,  premature,  of  pla- 
centa, 251 

Dextrin  by  rectum,  460 
Diaper,  159 

changing  of,  157 
Diapers,  99 

Diarrhea  in  infants,  331 
Diet  for  infants,  164 

for  prevention  of  overgrowth  of 
child,  452 
for  wet-nurse,  327 
in  first  stage  of  labor,  113 
in  incubator,  378 
in  pregnancy,  80 
in  puerperium,  141 
liquid,  452 
list  of,  452 
milk,  452 
Prochownik’s,  452 
raw  meat,  456 
semisolid,  452 
Dietary,  452 

Diet-table  in  Chicago  Lying-in 
Hospital,  378 
Difficulty  in  nursing,  330 
Digested  beef  by  rectum,  460 
Digestive  organs  of  child,  affec- 
tions of,  328 

Dilatation  in  phimosis,  341 
Dilators,  balloon,  231 
Hegar’s,  235 

Diplococcus  of  Neisser,  348 


INDEX 


493 


Disinfection  in  puerperal  infection, 
296 

Disorders  of  first  weeks  of  life,  328 
Doctor,  preparation  for,  in  first 
stage  of  labor,  no 
when  to  summon,  117 
Doderlein’s  pubiotomy  needle,  212 
Dolores,  58 
Douche,  222 
uterine,  224 
vaginal,  223 

Douche-cans,  sterilization  of,  439 
Douleurs,  58 
Dress  in  pregnancy,  75 
of  infant,  98 
of  nurse,  446 

Dressings,  sterilization  of,  433 
Drinking  glass,  ideal,  240 
Drop  method  of  giving  salt  solution 
by  rectum,  289,  290 
Dropper,  feeding-,  380 
Dropping,  56 

Dry  heat,  sterilization  by,  431 
labor,  57,  60 
Drying  up  milk,  326 

Eclampsia,  256 
symptoms,  256 
treatment,  257 

Economy  in  hospital  work,  423 
Ectopic  pregnancy,  252.  See  also 
Extra-uterine  pregnancy. 

Eczema  intertrigo,  159,  343 
treatment,  344 

Edema  of  extremities  in  pregnancy, 

243 

of  lungs,  treatment,  260 
Egg  and  milk,  456 
lemonade,  454 
Eggnog,  454 
Egg-water,  453 
Electricity  in  agalactia,  324 


! Elevated  Sims’  position,  270 
Embolism,  air-,  128 

in  third  stage  of  labor,  128 
puerperal,  297 
Embryotomy,  198 
instruments  for,  201 
j Enema,  ox-gall,  300 
Engorgement  of  breasts  in  puer- 
perium,  145,  307 

Enlargement  of  breasts  as  sign  of 
pregnancy,  73 
in  newborn,  344 

I Enteroptosis  after  pregnancy,  76 
Episiotomy,  61 

Eruptions  on  skin  in  infants,  342 
vesicular,  in  infants,  342 
Ether,  administering  of,  in  second 
stage  of  labor,  123 
Examination,  obstetric,  prepara- 
tion for,  217 
Excess  of  milk,  321 
Exercise  in  pregnancy,  81 
Extra-uterine  pregnancy,  252 
duties  of  nurse,  255 
symptoms,  254 

Eyes,  application  of  ice  to,  349 
infant’s,  care  of,  155 
infection  of,  347 
irrigation  of,  349,  351 
of  newborn  infant,  care  of,  132 
of  premature  infant,  care  of,  385 

! Facial  paralysis  after  forceps  de- 
livery, 353,  354 
j Fainting  in  pregnancy,  248 
Fallopian  tubes,  29 
fimbriae  of,  30  • 

False  pains  of  labor,  56.  103 
pelvis,  22,  23 
Feces,  green,  332 
, Fecundation,  40 
I Feeding,  infant,  392 


494 


INDEX 


Feeding,  infant,  amount  of  food, 
400 

caloric  method,  402 
nasal,  461 

premature  infant,  method  of,  380 
rectal,  459 
through  skin,  460 
Feeding-dropper,  380 
Feeling  life  as  sign  of  pregnancy,  74 
Feet,  keeping  warm,  in  incubator, 
377 

Femoral  hernia,  358 
Fertilization,  40 

Fetus,  head  of,  in  pregnancy,  43 
hiccup  of,  48 

in  diagnosis  of  pregnancy,  74 
in  uterus,  physiology  of,  46 
liver  of,  47 
Fever,  inanition,  333 
milk-,  307 

starvation,  164,  358 
thirst,  164 

Filling  of  bottles,  403 
Fimbriae,  30 

Fingers,  supernumerary,  358 
Fissures  of  nipple,  313 
Fistula,  rectovaginal,  in  puerpe- 
rium,  301 

vesicovaginal,  in  puerperium,  301 
Flannel  shirts,  infant’s,  97 
Flat  nipple,  312 
pelvis,  27 
Flaxseed  tea,  455 
Flour-ball,  455 
Fontanels,  43 

anterior  or  large,  43 
posterior  or  small,  43 
Foods,  artificial  infant,  408 

to  be  avoided  in  puerperium,  143 
Forceps,  axis-traction,  191 

De  Lee’s  long  uterine  packing, 
220 


Forceps  in  breech  extraction,  196 
operation,  190 

duties  of  nurse,  193 
list  of  instruments  for,  193 
Walcher  position,  197 
Simpson’s,  191 
Tarnier’s  axis- traction,  191 
vulsellum,  195 

Forceps-delivery,  injuries  in,  353 
Forceps-marks,  353,  354 
Formaldehyd  vapor,  generation  of, 
441 

Formalin  solution,  443 
Fossa  navicularis,  33 
Fourchet,  33 
Frontal  suture,  43 
, Fundus  uteri,  28 
Furb ringer’s  method  of  steriliza- 
tion of  hands,  425 
Furniture,  sterilization  of,  440 

Galactorrhea,  321 
Gauze,  gelatin,  437 
iodoform,  437 
lysol,  435 

packer,  tubular,  233 
plain  sterilized,  437 
Gavage,  Tarnier’s  method  of,  in 
premature  infants,  381 
I Gelatin  gauze,  437 
I Generative  organs,  anatomy  of,  21 
Genital  crease,  32 
Genitals,  care  of,  in  mother,  138 
external,  31 

in  pregnancy,  care  of,  89 
Gigli  wire  saws,  214 
Glass  cannula  for  intravenous 
transfusion,  226 
nipple-shield,  162 

Gloves,  rubber,  sterilization  of,  426 
De  Lee’s  method,  427 
Gonorrhea,  448 


INDEX 


495 


Gonorrhea,  treatment  of,  449 
Gowns,  sterilization  of,  440 
Granulations  of  navel,  345 
Grape-sugar  by  rectum,  460 
Green  stools,  332 
Gum,  red,  342 
white,  342 

Gum-arabic  water,  455 

Halsted’s  method  of  sterilization 
of  hands,  425 

Hands,  sterilization  of,  424 
Ahlf eld’s  method,  425 
De  Lee’s  method,  426 
Fiirb ringer’s  method,  425 
Halsted’s  method,  425 
Harelip,  356 

Headache  during  and  after  labor, 
i34 

in  puerperium,  304 
Head-and-mouth  guard,  206 
Heart-burn  in  pregnancy,  248 
Heat  and  light  in  operating  room, 
187 

dry,  sterilization  by,  431 
in  cesarean  section,  207 
prickly,  342 
rash,  342,  343 
Hebosteotomy,  21 1 
Hegar’s  dilators,  235 
Hematoma  after  pubiotomy,  216 
Hemorrhage  during  labor,  272 
in  pregnancy,  249 
of  newborn,  352 
postpartum,  272 
after-care  of,  277 
Hemorrhoids,  34 
Hernia,  358 
femoral,  358 
inguinal,  358 
umbilical,  358 
Hexenmilch,  244 


Hiccup  of  fetus,  48 
High  stomach  after  pregnancy,  76, 
78 

Hirst’s  bag,  231 

History  sheet  during  puerperium, 
141 

in  first  stage  of  labor,  114 
in  puerperal  infection,  295 
Home  nursing  vs.  hospital  nursing, 
419 

Hook,  Braun’s  decapitation,  198 
Hospital  nurse,  relations  to  patient, 

423 

nursing  vs.  home  nursing,  419 
work,  economy  in,  423 
Hot-water  bags,  complications  due 
to,  359 

Hygiene  of  pregnancy,  73 
Hymen,  33 

Hyperemesis  gravidarum,  238 
Hypodermoclysis,  225 
instruments  for,  225 

Ice,  application  of,  to  eyes,  349 
Icterus  neonatorum,  69,  341 
Ideal  drinking  glass,  240 
Imperforate  anus,  357 
Impregnation,  40 
Inanition  fever,  333 
Incubator,  368 
ambulance,  372 
Auvard,  368 
bed  of,  375 
care  of,  373 
diet  in,  378 

keeping  feet  warm  in,  377 
moisture  of,  374 
removal  of  premature  infant 
from,  386 

Sharp  and  Smith,  368 
station,  369 
temperature  of,  373 


496 


INDEX 


Incubator,  ventilation  of,  368,  375  I 
Indigestion  in  child,  328 
in  premature  infant,  388 
Induction  of  premature  labor,  230  I 
instruments  for,  230 
Infant,  baptism  of,  200 
bathing  of,  151 
care  of,  151 

after  operative  delivery,  189 
of  bowels,  156 
of  eyes,  155 
of  navel,  154 

conjunctivitis  in,  treatment  of, 
i55 

constipation  in,  156 
delivery  of,  before  doctor  arrives, 
262 

diet  for,  164 
feeding,  392 

amount  of  food,  400 
caloric  method,  402 
foods,  artificial,  408 
layette,  97 

newborn,  68.  See  also  Newborn 
infant. 

nursing  of,  160 

premature,  atelectasis  pulmo- 
num  of,  390 
bathing  of,  384 
blue  spells  of,  389 
care  of,  365 
general,  386 
convulsions  of,  390 
cyanosis  of,  389 
diseases  of,  387 
eyes  of,  care  of,  385 
feeding-dropper  for,  380 
incubator  for,  368 
indigestion  in,  388 
infection  in,  387 
massage  of,  386 
method  of  feeding,  380 


Infant,  premature,  mouth  of,  care 
of,  385 

nasal  infection  in,  388 
nose  of,  care  of,  385 
nursing  bottle  for,  380 
removal  of,  from  incubator,  386 
saddle-nose  of,  388 
sprue  in,  388 

Tarnier’s  method  of  gavage 
in,  381 

thrush  in,  388 

Winckel’s  permanent  bath  for, 
367 

pulse  of,  167 
respiration  of,  167 
scales,  101 
temperature  of,  167 
training  of,  167 
urination  in,  159 
wardrobe  of,  97 
weighing  of,  166 
Infection,  auto-,  283 
in  premature  infant,  387 
nasal,  in  premature  infants,  388 
of  eyes,  347 
of  mouth,  352 
of  newborn,  346 
of  throat,  352 
of  umbilicus,  346 
puerperal,  279.  See  also  Puer- 
peral infection. 

Inflammation  of  bladder  in  puer- 
perium,  330 

of  breast,  315.  See  also  Mastitis. 
Inguinal  hernia,  358 
Injuries,  operative,  of  newborn,  353 
to  brain  in  birth,  355 
Innominate  bones,  23 
Insanity,  puerperal,  304 
nourishment  in,  306 
prevention  of  suicide  in,  305 
salt  solution  in,  306 


INDEX 


49  7 


Insanity,  puerperal,  sleep  in,  306 
treatment  of,  305 
Instruments  for  embryotomy,  201 
for  induction  of  premature  labor, 
230 

for  pubiotomy,  213 
for  treatment  of  abortion,  234 
preparation  of,  for  operation,  187  I 
sterilization  of,  432 
Inverted  nipple,  312 
Involution  of  uterus,  55,  64 
Iodoform  gauze,  437 
Irrigation  of  eyes,  349,  351 
Irrigator,  rectal,  156 
Ischuria  paradoxa,  248 
in  puerperium,  66 
Itching  of  pudenda  in  pregnancy. 
245 

Jacket,  confinement,  93 
Jaundice  of  newborn,  69,  341 
Junket.  455 

Kabo  abdominal  supporter,  77 
Kidney  pains,  59 
Kidneys  in  pregnancy,  86 
in  puerperium,  66 
of  newborn  infant,  70 
Knee-chest  position,  238 
Koumiss,  355 

Labia  majora,  32 
minora,  32 
Labor,  54 

after-pains  of,  61 
care  during,  103 

among  destitute,  41 1 
complications  during,  262 
delivery  of  child  before  doctor 
arrives,  262 

dropping  as  sign  of,  56 
32 


Labor,  dry,  57,  60 
false  pains  of,  56,  103 
first  stage  of,  57 

care  during,  103 
diet  in,  113 

general  instructions  in,  114 
history-sheet  in,  114 
preparation  for  doctor  in, 
no 

of  bed  for,  107 
of  patient  for,  109 
of  room  for,  105 
when  to  summon  doctor,  1 1 7 
headache  during  and  after,  134 
hemorrhage  during,  272 
lightening  as  sign  of,  55 
nursing  during,  103 
pains,  58,  103 

false,  as  sign  of  labor,  56,  103 
period  of  dilatation,  57 
of  expulsion,  57 
placental  stage,  57 
powers  of,  58 
premature,  54,  55 
induction  of,  230 
instruments  for,  230 
premonitory  symptoms,  55 
satchel,  list  of  articles  in,  412 
second  stage  of,  57 

administering  ether  in,  123 
anesthesia  in,  123 
care  during,  118 
chloral  in,  120 
cramp  in  leg  during,  119 
morphin  in,  120 
pantopon  in,  120 
scopolamin  in,  120 
show  as  sign  of,  57,  103 
signs  of,  54 
stages  of,  57 
third  stage  of,  57 

air-embolism  in,  128 


498 

Labor,  third  stage  of,  care  after, 
134 

during,  125 

guarding  uterus  in,  125,  127 
expelling  placenta  in,  127 
lacerations  of  perineum  in, 

131 

complete,  special  care 
in,  140 

perineorrhaphy  in,  129 
Lacerations  of  perineum,  complete, 
in  third  stage  of  labor,  spe- 
cial care  in,  140 
in  third  stage  of  labor,  13 1 
Lambdoid  suture,  43 
Lanugo,  365 
Layette,  infant’s,  97 
Leg,  cramp  in,  during  second  stage 
of  labor,  119 
milk-,  297 

Leggings,  obstetric,  94 
sterilization  of,  440 
Lemonade,  egg,  454 
Leukorrhea  in  pregnancy,  245 
Ligaments,  broad,  31 
Light  and  heat  in  operating  room, 
187 

in  cesarean  section,  207 
Lightening,  55 
Linea  gravidarum,  51,  52 
Linen  bobbin,  439 

suture  yarn,  sterilization  of,  439 
Liquid  diet,  452 
Liquor  amnii,  42,  59 
cresolis  compositus,  443 
Lithotomy  position,  185,  186 
Liver  of  fetus,  47 
Livid  asphyxia,  360 
Lochia,  63 

care  of,  after  pubiotomy,  217 
cruenta,  63 
odor  of,  64 


Lochia  purulenta,  64 
sanguinolenta,  63 
serosa,  64 
serosanguineous,  63 
Lockjaw,  359 
Lues,  449 

I Lungs,  edema  of,  treatment,  260 
in  pregnancy,  51 
Lysol  gauze,  435 
solution,  443 

Major  operations,  190 
Mammary  gland.  See  Breast. 
Mania  in  puerperium,  304 
Marasmus,  334 
Mask  of  pregnancy,  52 
Massage  in  puerperium,  148 
of  breast,  309-312 
in  agalactia,  323 
of  premature  infant,  386 
Mastitis,  315 

Bier’s  method  of  treating,  320 
etiology,  316 
symptoms,  317 
treatment,  317 
Materna  glass,  406 
Maternal  changes  of  pregnancy,  49 
impressions,  82 

nursing,  contraindications  to,  393 
Meat  cure,  455 
diet,  raw,  456 
Meat-extract  ice,  456 
Meatus  urinarius,  31,  33 
Meconium,  70 

Melancholia  in  pregnancy,  249 
in  puerperium,  304 
Melena  neonatorum,  333,  352 
Menses,  cessation  of,  in  diagnosis 
of  pregnancy,  73 
I Menstruation,  38 
in  newborn,  345 
i uterus  during,  38 


INDEX 
[ 


INDEX 


499 


Mental  condition  in  puerperium,  67  I 
Mercury,  bichlorid  of,  preparation 
of  solutions  of,  442 
Milk,  abnormal,  325 

amount  required  for  feedings, 
table  of,  401 
and  egg,  456 
certified,  405 
composition  of,  395 
diet,  452 

digested  with  acid,  456 
drying  up,  326 
excess  of,  321 

human  and  cows’,  table  of  com- 
parison, 395 

obtaining  of,  for  analysis,  394 
lower,  obtaining  of,  400 
mixed,  404 
modification  of,  395 
apparatus  for,  398 
mothers’,  substitutes  for,  395 
peptonized,  407 
by  rectum,  459 
cold  process,  456 
warm  process,  457 
with  egg,  by  rectum,  459 
quality  of,  404 
scarcity  of,  321 
siphon,  399 

sterilization  of,  403,  457 
under,  obtaining  of,  400 
upper,  obtaining  of,  398 
witches’,  344 
Milk-fever,  66,  307 
Milk-leg,  297 
Milk-shake,  457 
Milk-sugar,  396 
Milk-toast,  peptonized,  457 
Mind  in  pregnancy,  82 
Minor  operations,  217 
Miscarriage,  55 
Mixed  milk,  404 


I Modification  of  milk,  395 
apparatus  for,  398 
Moisture  of  incubator,  374 
Momburg’s  belt,  276 
Mons  veneris,  32 
Monstrosities,  356 
Montgomery’s  tubercles,  36 
Morbus  caeruleus,  337 
Morning  sickness,  53 

in  diagnosis  of  pregnancy,  73 
Morphin  in  second  stage  of  labor, 
120 

Mother,  care  of,  after  operative  de- 
livery, 190 

during  puerperium,  daily  care  of, 
135 

Mothers’  milk,  substitutes  for,  395 
Mouth  in  pregnancy,  52 
infection  of,  352 

of  premature  infant,  care  of,  385 
Mouth-and-head  guard,  206 
Mulberry  nipple,  312 
Mutilating  operations,  preparation 
for,  200 

Mutton  broth,  457 

Nasal  feeding,  461 

infection  in  premature  infants, 
388 

Nausea  in  pregnancy,  237 
Navel,  care  of,  154 
granulations  of,  345 
of  newborn  infant,  70 
Needle,  De  Lee’s,  for  hypodermo- 
clysis,  225 
pubiotomy,  212 

Neglected  transverse  presentations, 
198 

| Neisser,  diplococcus  of,  348 
Nervous  system  in  pregnancy,  54 
Nest-building,  40 
Neuralgia  in  pregnancy,  54 


500 


INDEX 


Newborn  infant,  68 
affections  of,  328 
atelectasis  pulmonum  of,  68 
bed  of,  100 
bowels  of,  70 
cry  of,  68 

eyes  of,  care  of,  132 
first  care  of,  132 
weeks  of,  68 
jaundice  of,  69 
kidneys  of,  70 
navel  of,  70 
outfit  for,  97 
skin  of,  69 
sleep  of,  69 
temperature  of,  69 
wardrobe  of,  97 
weight  of,  45,  71 
Newspapers,  sterilization  of,  435 
Nipple,  36 

abnormalities  of,  312 
bifid,  312 
blisters  of,  313 
cracks  of,  313 
fissures  of,  313 
flat,  312 

for  babies  with  cleft  palate,  356 

inverted,  312 

mulberry,  312 

polypoid,  312 

split,  312 

Nipple-shield,  glass,  162 
Wansbrough’s,  314 
Nitrate  of  silver  method  for  preven- 
tion of  ophthalmia  neonatorum, 
132 

Nose  of  premature  infant,  care  of, 

385 

saddle-,  of  premature  infant,  388 
Nourishment  in  puerperal  infection, 
289 

insanity,  306 


Nurse,  444 

articles  needed  by,  445 
asepsis  of,  during  puerperium,  285 
care  of,  in  infection,  352 
delivery  of  child  by,  262 
deportment  of,  446 
dress  of,  446 

duties  of,  during  forceps  opera- 
tion, 193 

in  extra-uterine  pregnancy,  255 
engagement  of,  90 
hospital,  relations  to  patient,  423 
in  puerperal  infection,  294 
instructions  for,  92 
visiting,  duties  of,  during  puer- 
perium, 414 
satchel  of,  417 
visits  of,  93 
wet-,  care  of,  326 
Nursery,  care  in,  420 
conveniences,  100 
Nursing  after  patient  is  up,  150 
bottle  for  premature  infants,  380 
difficulty  in,  330 
during  labor,  103 
puerperium,  103 
hospital,  vs.  home,  419 
maternal,  contraindications  to, 
393 

of  infant,  160 
visiting,  41 1 
Nutritious  coffee,  457 

Oatmeal-water,  408 
Obstetric  cases,  list  of  articles  for, 

91 

complications,  237 
examination,  preparation  for,  217 
leggings,  94 
operations,  178 

Occipital  presentation,  four  posi- 
tions of,  1 71 


INDEX 


501 


Occlusion  of  anus,  357 
Operating  room,  light  and  heat  in, 
187 

Operations,  178 
care  after,  188 

forceps,  190.  See  also  Forceps 
operation. 

in  private  home,  181 
major,  190 
minor,  217 

mutilating,  preparation  for,  200 
preparation  for,  180 
of  instruments  for,  187 
of  patient  for,  184 
of  room  for,  183 

Operative  injuries  of  newborn,  353 
Ophthalmia  neonatorum,  347 
care  of  nurse  in,  352 
Crede’s  method  for  prevention 
of,  132 

prevention  of,  348 
treatment  of,  349 
Orders,  422 
Os  uteri,  28 
Ossa  innominata,  22 
Osteomalacic  pelvis,  27 
Ovary,  31 

Overgrowth  of  child,  diet  for  pre- 
vention of,  452 
Overlying  child,  360 
Ovulation,  37,  39 
Ovum,  40 
Ox-gall  enema,  300 

Packing  uterus  with  gauze,  220 
Pad-holder,  92 
Pains,  after-,  61,  299 
bearing-down,  59 
false,  of  labor,  56,  103 
in  abdomen  in  pregnancy,  247 
kidney  59 
labor,  58,  103 


Palate,  cleft,  356 

nipple  for  babies  with,  356 
Pallid  asphyxia,  360 
Pantopon  in  second  stage  of  labor, 
120 

Paralysis,  facial,  after  forceps  de- 
livery, 353,  354 

Patient,  preparation  of,  for  first 
stage  of  labor,  109 
for  operation,  184 
Pelves,  varieties  of,  26 
Pelvimeters,  111 
Pelvis,  anatomy  of,  21 
brim  of,  24 
contracted,  27 
deformed,  27 
false,  22,  23 
flat,  27 
inlet  of,  24 
osteomalacic,  27 
outlet  of,  24 
small,  24 
soft  parts  of,  28 
true,  22,  24 
upper  strait  of,  24 
Pendulous  abdomen  in  pregnancy, 
246 

Peptic  salt,  388 
Peptonized  milk,  407 
by  rectum,  459 
cold  process,  456 
warm  process,  457 
with  egg  by  rectum,  459 
milk-toast,  457 
Perineal  body,  34 
Perineorrhaphy,  129,  218 
Perineum,  32,  33 

lacerations  of,  complete,  in  third 
stage  of  labor,  special  care 
in,  140 

in  third  stage  of  labor,  13 1 
I Peritoneum,  31 


502 


IXDEX 


Permanganate  method  of  steriliza- 
tion of  hands,  425 
Pernicious  vomiting,  238 
Pessary,  air,  231 
Phimosis,  338 

Phlegmasia  alba  dolens,  297 
Piles,  34 

Pillow-slips,  sterilization  of,  440 
Pitchers,  sterilization  of,  439 
Pituitrin  in  agalactia,  322 
Placenta,  41,  42,  46,  61 
abruption  of,  251 
examination  of,  269 
expelling  of,  127 
prasvia,  250 

premature  detachment  of,  251 
Pneumonia,  336 
Point  of  direction,  171 
Polypoid  nipple,  312 
Polyuria  in  puerperium,  66 
Pomeroy’s  bag,  231 
Position,  169 
diagnosis  of,  173 
knee-chest,  238 
lithotomy,  185,  186 
posterior,  176 
Sims’,  elevated.  270 
Trendelenburg,  in  bed,  271 
Walcher,  195 

for  forceps  operation,  196 
Posterior  positions,  176 
Postpartum  hemorrhage,  272 
after-care,  277 
visiting  bag.  417,  418 
Pregnancy,  49 

abdominal  supporter  in,  76 
alcohol  in.  81 
areolar  signs  of.  73 
bathing  in,  87 

bed-sores  in,  prevention  of,  242 
blood  in,  50 
bowels  in,  84 


Pregnancy,  breast  in,  50,  73 
breasts  in,  care  of,  77,  89 
cessation  of  menses  in  healthy 
woman  as  sign  of,  73 
constipation  in,  54 
convulsions  in,  256 
corsets  in,  76 
high  stomach  from,  75 
decubitus  in,  prevention  of,  242 
diagnosis  of,  73 
diet  in,  80 
disorders  of,  237 
dress  in,  75 
eclampsia  in,  256 
ectopic,  252.  See  also  Preg- 
nancy, extra-uterine. 
edema  of  extremities  in,  243 
enlargement  of  breasts  as  sign  of 
73 

enteroptosis  after,  76 
exercise  in,  81 
extra-uterine,  252 
duties  of  nurse,  255 
symptoms  of,  254 
fainting  in,  248 
feeling  life  as  sign  of,  74 
fetus  as  sign  of,  74 
frequent  urination  in,  248 
general  changes  in,  51 
genitals  in,  care  of,  89 
head  of  fetus  in,  43 
heart-bum  in,  248 
hemorrhage  in.  249 
high  stomach  after,  76,  78 
hygiene  of,  73 

h)-peremesis  gravidarum,  238 

itching  of  pudenda  in,  245 

kidneys  in,  86 

length  of,  54 

leukorrhea  in,  245 

local  changes  in,  49 

lungs  in,  51 


INDEX 


503 


Pregnancy,  mask  of,  52 
maternal  changes  of,  49 
impressions  in,  82 
melancholia  in,  249 
mind  in,  82 
mode  of  living  in,  75 
morning  sickness  in,  53,  73 
mouth  in,  52 
nausea  of,  237 
nervous  system  in,  54 
neuralgia  in,  54 
pains  in  abdomen  in,  247 
pendulous  abdomen  in,  246 
preservation  of  figure  in,  78 
pride  of,  78 
pruritus  in,  245 
ptyalism  in,  52 
quickening  as  sign  of,  74 
shoes  in,  78 
skin  in,  52,  87 
taste  in,  53 
teeth  in,  52,  248 
toxemia  in,  87,  242 
urine  in,  51 
uterus  in,  49 
vagina  in,  49 
varicose  veins  in,  80,  243 
vomiting  in,  237 
vulva  in,  50 

Premature  detachment  of  placenta, 

251 

infant,  atelectasis  pulmonum  of, 
390 

bathing  of,  384 
blue  spells  of,  389 
care  of,  365 
general,  386 
convulsions  of,  390 
cyanosis  of,  389 
diseases  of,  387 
eyes  of,  care  of,  385 
feeding-dropper  for,  380 


Premature  infant,  incubator  for, 

367 

indigestion  in,  388 
infection  in,  387 
massage  of,  386 
method  of  feeding,  380 
mouth  of,  care  of,  385 
nasal  infection  in,  388 
nose  of,  care  of,  385 
nursing  bottle  for,  380 
removal  of,  from  incubator, 
386 

saddle-nose  of,  388 
sprue  in,  388 

Tarnier’s  method  of  gavage 
in,  381 

thrush  in,  388 

WinckePs  permanent  bath  for, 

367 

labor,  54,  55 

induction  of,  230 
instruments  for,  230 
Presentation,  169 
and  position,  169 
breech,  177,  269 
diagnosis  of,  173 
occipital,  four  positions  of,  171 
shoulder,  177 
transverse,  177 
neglected,  198 

Pressure-marks  from  forceps,  353, 
354 

Prickly  heat,  342 
Pride  of  pregnancy,  78 
Prochownik’s  diet,  452 
Prolapse  of  cord,  270 
Proprietary  infant  foods,  408 
Protargol  in  prevention  of  oph- 
thalmia neonatorum , 133 
Pruritus  in  pregnancy,  245 
Ptyalism,  52 
Puberty,  37 


504 


INDEX 


Pubes,  26 
Pubiotomy,  21 1 
after-care,  214 
care  of  lochia  after,  217 
catheterization  after,  217 
hematoma  after,  216 
instruments  for,  213 
needles,  212 
operation,  212 

Pudenda,  itching  of,  in  pregnancy, 
245 

Puerperal  embolism,  297 
infection,  279 
disinfection,  296 
frequency  and  source,  283 
history  of,  280 
sheet,  295 

medicinal  treatment,  293 
nourishment,  289 
prevention  of,  284 
rectal  infusion,  289 
salt  solution,  289 
surgical  treatment,  293 
symptoms  of,  286 
the  child,  293 
the  nurse,  294 
treatment  of,  287 
insanity,  304 

nourishment  in,  306 
prevention  of  suicide  in,  305 
salt  solution  in,  306 
sleep  in,  306 
treatment,  305 
thrombosis,  297 
Puerperium,  61 

abnormal  milk  in,  325 
abnormalities  of  nipples  in,  312 
agalactia  in,  321 
asepsis  of  breasts  during,  286 
of  nurse  during,  285 
bath  in,  147,  151 
bladder  in,  145 


Puerperium,  bowels  in,  67,  144 
breasts  in,  65 
care  of,  135 
care  during,  135 
catheterization  in,  146 
complications  of,  279 
constipation  in,  300 
cystitis  in,  303 
diet  in,  141 

diseases  of  breasts  in,  307 
drying  up  milk  in,  326 
duties  of  visiting  nurse  during, 
414 

engorgement  of  breast  in,  65, 145, 

307 

excess  of  milk  in,  321 
foods  to  be  avoided  in,  143 
galactorrhea  in,  321 
general  changes  in,  66 
treatment,  147 
genitals  in,  care  of,  138 
headache  in,  304 
history-sheet  during,  141 
inflammation  of  bladder  in,  303, 
315 

insanity  in,  304 
ischuria  paradoxa  in,  66 
kidneys  in,  66 
massage  in,  148 
mastitis  in,  315 
mental  condition  in,  67 
mother  during,  daily  care  of,  135 
nursing  after  patient  is  up,  150 
during,  103 
polyuria  in,  66 
pulse  in,  66,  148 
rectovaginal  fistula  in,  301 
respiration  in,  148 
retention  of  urine  in,  66 
scarcity  of  milk  in,  321 
skin  in,  67 
sleep  in,  147 


INDEX 


505 


Puerperium,  temperature  in,  66, 148  I 
time  of,  diagnosis,  74 
of  getting  up,  148 
tympany  in,  299 
urethra  in,  145 
uterus  in,  61 
vagina  in,  64 

vesicovaginal  fistula  in,  301 
visitors  during,  148,  15 1 
vulva  in,  64 

Pulse  in  puerperium,  66,  148 
of  infant,  167 
Pump,  breast-,  163 
Punch,  rum,  458 

Quality  of  milk,  404 
Quickening  as  sign  of  pregnancy,  74 

Rash,  heat,  342,  343 
Recipes,  453 
Rectal  feeding,  459 
infusion  in  puerperal  infection, 
289 

irrigator,  156 

Rectovaginal  fistula  in  puerperium, 
301 

Rectum,  31 
Red  gum,  342 

Reproduction,  function  of,  37 
Reproductive  system,  anatomy  and 
physiology  of,  21 
Respiration,  artificial,  362 
Byrd’s  method,  362 

De  Lee’s  modification, 

362,  363 

Sylvester’s  method,  363 
in  puerperium,  148 
of  infant,  167 

Respiratory  tract  of  infants,  affec- 
tions of,  335 

Retention  of  urine  in  puerperium, 
66 


Rice-water,  458 
Rochester  sterilizer,  430 
Room  for  operation,  preparation 
of,  183 

preparation  of,  for  first  stage  of 
labor,  105 
Rotation,  24 

Rubber  gloves,  sterilization  of,  426 
De  Lee’s  method,  427 
Rum  punch,  458 

Sacrum,  22 

Saddle-nose  of  premature  infant, 
388 

Sagittal  suture,  43 
Salt,  peptic,  388 
solution,  443 

administration  of,  225 
by  rectum,  459 

drop  method  of  giving,  289, 
290 

in  puerperal  infection,  289 
insanity,  306 
through  skin,  460 
Salvarsan  in  syphilis,  450 
Sanitary  seat  covers,  88 
Satchel,  labor,  list  of  articles  in,  41 2 
visiting  nurse’s,  417 
i Saws,  Gigli  wire,  214 
Scales,  infant,  101 
Scarcity  of  milk,  321 
Scissors,  Smellie’s  perforating,  199 
Scopolamin  in  second  stage  of  labor, 
120 

j Semisolid  diet,  452 
Semmelweis  and  puerperal  infec- 
tion, 280 

I Separation  of  cord,  delayed,  345 
j Sex,  determination  of,  83 
Sharp  and  Smith  incubator,  368 
Sheets,  sterilization  of,  440 
| Shield,  nipple-,  314 


506 


INDEX 


Shirts,  infant’s,  97 
Shoes  in  pregnancy,  78 
Shoulder  presentation,  177 
Show,  57,  103 
Silk,  sterilization  of,  438 
Silver  nitrate  method  for  preven- 
tion of  ophthalmia  neonatorum, 
132 

Simpson’s  forceps,  191 
Sims’  position,  elevated,  270 
Sinus  lactiferus,  35 
Siphon,  milk,  399 
Skin,  affections  of,  in  infants,  342 
feeding  through,  460 
in  pregnancy,  52,  87 
in  puerperium,  67 
of  newborn  infant,  69 
Skin-eruptions  in  infants,  342 
Sleep  in  puerperium,  147 
of  newborn  infant,  69 
Smellie’s  perforating  scissors,  199 
Snuffles,  335 

Solutions,  preparation  of,  441 
Spasms,  358 
Specific  disease,  449 
Spermatozoid,  40 
Sphincter  ani,  34 
Split  nipple,  312 
Sponges,  covered,  433 
Sprue,  333 

in  premature  infant,  388 
Starvation  fever,  164,  358 
Sterile  water,  preparation  of,  441 
Sterilization,  92 
by  dry  heat,  431 
methods  of,  424 
of  apartments,  440 
of  basins,  439 
of  bed-pans,  439 
of  brushes,  433 
of  catgut,  438 
of  douche-cans,  439 


Sterilization  of  dressings,  433 
of  furniture,  440 
of  gowns,  aprons,  etc.,  440 
of  hands,  424 

Ahlfeld’s  method,  425 
De  Lee’s  method,  426 
Fiirbringer’s  method,  425 
Halsted’s  method,  425 
of  instruments,  432 
of  linen  suture  yarn,  439 
of  milk,  403 
of  newspapers,  435 
of  pitchers,  439 
of  rubber  gloves,  426 

De  Lee’s  method,  427 
of  silk,  438 
of  sutures,  438 
Sterilized  milk,  457 
Sterilizer,  De  Lee’s  glove,  428 
Rochester,  430 
Sterilizers,  430 
Stockings,  infant’s,  99 
obstetric,  94 

Stomach,  high,  after  pregnancy,  76, 
78 

Stools,  green,  332 
Striae  gravidarum,  51,  52 
Strophulus,  342 
Submammary  abscess,  316 
Sugar,  grape-,  by  rectum,  460 
Supernumerary  fingers,  358 
toes,  358 

Suture  material,  preparation  of,  438 
yarn,  linen,  sterilization  of,  439 
Sutures,  43 

removal  of,  220 

Sylvester’s  method  of  artificial  res- 
piration, 363 
Symphysiotomy,  21 1 
after-care,  214 
bed,  216 
bed-frame,  215 


INDEX 


50  7 


Symphysis  pubis,  26 
Symptoms,  recording  of,  421 
Syphilis,  449 

prevention  of  contagion  in,  450 
treatment  of,  450 

Tamponade,  lysol  gauze  for,  435 
uterine,  220 

Tarnier’s  axis-traction  forceps,  191 
method  of  gavage  in  premature 
infants,  381 
Taste  in  pregnancy,  53 
T-bindec,  92 
Tea,  flaxseed,  455 
Teeth  in  pregnancy,  52,  248 
Temperature  in  puerperium,  66, 148 
of  incubator,  373 
of  infant,  167 
of  newborn  infant,  69 
Tetanus,  359 
Teterelle,  382,  383 
Therapeutic  abortion,  234 
Thirst  fever,  164 
Throat,  infection  of, ^5^2 
Thrombosis,  puerperal,  297 
Thrush,  333  'Z 

in  prematur^infants,  388 
Thyroid  extract  in  agalactia,  322 
Toast-water,  4.58 
Toes,  supernumerary,  358 
Tongue-tie,  357 
Towels,  sterilization  of,  440 
Toxemia  in  pregnancy,  87,  242 
Tracheal  catheter,  360 
Training  of  infant,  167 
Transverse  presentation,  177 
neglected,  198 

Trendelenburg  posture  in  bed,  271 
True  pelvis,  22,  24 
Tubercles  of  Montgomery,  36 
Tubular  gauze  packer,  233 
Tympany  in  puerperium,  299 


Umbilical  cord,  43 

delayed  separation  of,  345 
prolapse  of,  270 
hernia,  358 

Umbilicus,  infection  of,  346 
Ureters,  31 
Urethra,  31 

in  puerperium,  145 
Uric  acid  in  urine,  338 
Urinary  organs  of  infants,  affec- 
tions of,  337 

Urination,  delayed,  in  infant,  337 
difficult  postpartum,  66 
frequent,  in  pregnancy,  248 
in  infant,  159 
Urine  in  pregnancy,  51 

retention  of,  in  puerperium,  66 
uric  acid  in,  338 
Uterine  curettage,  224 
douche,  224 
tamponade,  220 
Uterus,  38 

broad  ligaments  of,  31 
care  of,  during  third  stage  of 
labor,  125,  127 
cervix  of,  28 
during  menstruation,  38 
fetus  in,  physiology  of,  46 
fundus  of,  28 
in  pregnancy,  49 
in  puerperium,  61 
involution  of,  55,  64 
os  of,  28 

packing  of,  with  gauze,  220 
shape  and  size  of,  at  term,  42 

Vagina,  29 

in  pregnancy,  49 
in  puerperium,  64 
j Vaginal  cesarean  section,  210 
douche,  223 

j Varicose  veins  in  pregnancy,  80,  243 


508 


INDEX 


Veins,  varicose,  in  pregnancy,  80, 
243 

Venereal  diseases,  448 

general  consideration,  451 
Ventilation  of  incubator,  368,  375 
Vernix  caseosa,  69 
Version,  197 

Vesicovaginal  fistula  in  puerperium, 
301 

Vesicular  eruptions  in  infants,  342 
Vestibule,  33 
Villi,  41,  46 
Visiting  bag,  417,  418 
nurse,  duties  of,  during  puerpe- 
rium, 414 
satchel  of,  417 
nursing,  41 1 

Visitors  during  puerperium,  148, 

151 

Visits  of  nurse,  95 
Vomiting  in  child,  330 
in  pregnancy,  237 
pernicious,  238 
Voorhees’  bag,  231 
Vulsellum  forceps,  195 
Vulva,  29,  32 
anatomy  of,  32 
in  pregnancy,  50 
in  puerperium,  64 
Vulvitis  in  newborn,  345 


Walcher  position,  195 

for  forceps  operation,  196 
Wansbrough’s  nipple-shield,  314 
Ward,  care  in,  419 
Wardrobe,  infant’s,  97 
Warm  feet  of  incubator  infant,  377 
Warren  dresses,  98 
Water,  sterile,  preparation  of,  441 
Water-blisters,  342 
Waters,  bag  of,  59 
j Wehen,  58 

Weighing  of  infant,  166 
Weight  chart  of  newborn  infant,  72 
of  newborn  infant,  45,  71 
Wet-nurse,  care  of,  326 
Whey,  406,  458 
champagne,  454 
wine,  458 
White  gum,  342 

Wiegand-Martin  method  of  de- 
livering after-coming  head,  176 
Winckel’s  permanent  bath  for  pre- 
mature infants,  367 
Wine  whey,  458 
Wire  saws,  Gigli,  214 
Witches’  milk,  344 


Yarn,  linen  suture,  sterilization  of, 
439 


DATE  DUE 


DEC  - i ip 

U 

201-5503 

PRINTED  IN  U.S.A. 

